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Anthem Blue Cross Blue Shield of California prior authorization, page 28

CPT code lookup

Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.

Prior authorization codes

Prior authorization codes
CodeDescriptionSource
0405UOncology (pancreatic), 59 methylation haplotype block markers, next-generation sequencing, plasma, reported as cancer signal detected or not detectedCalifornia PPO Prior Authorization List, Pg 62 Original policy
0409UOncology (solid tumor), DNA (80 genes) and RNA (36 genes), by next-generation sequencing from plasma, including single nucleotide variants, insertions/deletions, copy number alterations, microsatellite instability, and fusions, report showing identified mutations with clinical actionabilityCalifornia PPO Prior Authorization List, Pg 63 Original policy
0410UOncology (pancreatic), DNA, whole genome sequencing with 5-hydroxymethylcytosine enrichment, whole blood or plasma, algorithm reported as cancer detected or not detectedCalifornia PPO Prior Authorization List, Pg 63 Original policy
0411UPsychiatry (e.g., depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6California PPO Prior Authorization List, Pg 63 Original policy
0413UOncology (hematolymphoid neoplasm), optical genome mapping for copy number alterations, aneuploidy, and balanced/complex structural rearrangements, DNA from blood or bone marrow, report of clinically significant alterationsCalifornia PPO Prior Authorization List, Pg 63 Original policy
0414UOncology (lung), augmentative algorithmic analysis of digitized whole slide imaging for 8 genes (ALK, BRAF, EGFR, ERBB2, MET, NTRK1-3, RET, ROS1), and KRAS G12C and PD-L1, if performed, formalin-fixed paraffin-embedded (FFPE) tissue, reported as positive or negative for each biomarkerCalifornia PPO Prior Authorization List, Pg 63 Original policy
0417URare diseases (constitutional/heritable disorders), whole mitochondrial genome sequence with heteroplasmy detection and deletion analysis, nuclear-encoded mitochondrial gene analysis of 335 nuclear genes, including sequence changes, deletions, insertions, and copy number variants analysis, blood or saliva, identification and categorization of mitochondrial disorder-associated genetic variantsCalifornia PPO Prior Authorization List, Pg 63 Original policy
0419UNeuropsychiatry (e.g., depression, anxiety), genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotypeCalifornia PPO Prior Authorization List, Pg 63 Original policy
0420UOncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR (ddPCR) analysis of 6 single-nucleotide polymorphisms (SNPs) genes TERT and FGFR3, urine, algorithm reported as a risk score for urothelial carcinomaCalifornia PPO Prior Authorization List, Pg 63 Original policy
0422UOncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre- treatment cell-free circulating DNA analysis using next- generation sequencing, algorithm reported as a quantitative change from baseline, including specific alterations, if appropriateCalifornia PPO Prior Authorization List, Pg 63 Original policy
0424UOncology (prostate), exosome-based analysis of 53 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RTqPCR), urine, reported as no molecular evidence, low-, moderate- or elevated-risk of prostate cancerCalifornia PPO Prior Authorization List, Pg 63 Original policy
0425UGenome (e.g., unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis, each comparator genome (e.g., parents, siblings)California PPO Prior Authorization List, Pg 63 Original policy
0426UGenome (e.g., unexplained constitutional or heritable disorder or syndrome), ultra-rapid sequence analysisCalifornia PPO Prior Authorization List, Pg 63 Original policy
0434UDrug metabolism (adverse drug reactions and drug response), genomic analysis panel, variant analysis of 25 genes with reported phenotypesCalifornia PPO Prior Authorization List, Pg 63 Original policy
0438UDrug metabolism (adverse drug reactions and drug response), buccal specimen, gene-drug interactions, variant analysis of 33 genes, including deletion/ duplication analysis of CYP2D6, including reported phenotypes and impacted gene- drug interactionsCalifornia PPO Prior Authorization List, Pg 63 Original policy
A2001Innovamatrix AC, per square centimeterCalifornia PPO Prior Authorization List, Pg 63 Original policy
A2002Mirragen advanced wound matrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 63 Original policy
A2004Xcellistem, 1mgCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2005Microlyte matrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2006Novosorb synpath dermal matrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2007Restrata, per square centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2008TheraGenesis, per square centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2009Symphony, per square centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2010Apis, per square centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2011Supra SDRM, per square centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2012Suprathel, per square centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2013InnovaMatrix FS, per square centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2014Omeza Collagen Matrix, per 100 mgCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2015Phoenix Wound Matrix, per sq cmCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2016PermeaDerm B, per sq cmCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2017PermeaDerm Glove, eachCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2018PermeaDerm C, per sq cmCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2019Kerecis omega3 MariGen Shield, per square centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2020Ac5 advanced wound system (Ac5)California PPO Prior Authorization List, Pg 64 Original policy
A2021NeoMatriX, per square centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2025Miro3D, per cubic centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2030Miro3D fibers, per milligramCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2031MiroDry wound matrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2032Myriad matrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2033Myriad morcells, 4 milligramsCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2034Foundation DRS Solo, per sq cmCalifornia PPO Prior Authorization List, Pg 64 Original policy
A2035Corplex P or Theracor P or Allacor P, per milligramCalifornia PPO Prior Authorization List, Pg 65 Original policy
A4540Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper armCalifornia PPO Prior Authorization List, Pg 65 Original policy
A4596Cranial electrotherapy stimulation (CES) system supplies and accessories, per monthCalifornia PPO Prior Authorization List, Pg 65 Original policy
B4164Parenteral nutrition solution; carbohydrates (dextrose), 50% or less (500 ml = 1 unit) - home mixCalifornia PPO Prior Authorization List, Pg 65 Original policy
B4168Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) - home mixCalifornia PPO Prior Authorization List, Pg 65 Original policy
B4176Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mixCalifornia PPO Prior Authorization List, Pg 65 Original policy
B4178Parenteral nutrition solution; amino acid, greater than 8.5%, (500 ml = 1 unit) - home mixCalifornia PPO Prior Authorization List, Pg 65 Original policy
B4180Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) - home mixCalifornia PPO Prior Authorization List, Pg 65 Original policy
B4185Parenteral nutrition solution, not otherwise specified, 10 grams lipidsCalifornia PPO Prior Authorization List, Pg 65 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.

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