Anthem Blue Cross Blue Shield of California prior authorization, page 29
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
| Code | Description | Source |
|---|---|---|
| B4187 | Omegaven, 10 grams lipids | California PPO Prior Authorization List, Pg 65 Original policy |
| B4189 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix | California PPO Prior Authorization List, Pg 65 Original policy |
| B4193 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix | California PPO Prior Authorization List, Pg 65 Original policy |
| B4197 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix | California PPO Prior Authorization List, Pg 65 Original policy |
| B4199 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, over 100 grams of protein - premix | California PPO Prior Authorization List, Pg 65 Original policy |
| B4216 | Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) home mix per day | California PPO Prior Authorization List, Pg 65 Original policy |
| B4220 | Parenteral nutrition supply kit; premix, per day | California PPO Prior Authorization List, Pg 65 Original policy |
| B4222 | Parenteral nutrition supply kit; home mix, per day | California PPO Prior Authorization List, Pg 65 Original policy |
| B4224 | Parenteral nutrition administration kit, per day | California PPO Prior Authorization List, Pg 65 Original policy |
| B5000 | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - Aminosyn-RF, NephrAmine, RenAmine - premix | California PPO Prior Authorization List, Pg 65 Original policy |
| B5100 | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic, HepatAmine - premix | California PPO Prior Authorization List, Pg 65 Original policy |
| B5200 | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-branch chain amino acids - FreAmine-HBC - premix | California PPO Prior Authorization List, Pg 66 Original policy |
| B9004 | Parenteral nutrition infusion pump, portable | California PPO Prior Authorization List, Pg 66 Original policy |
| B9006 | Parenteral nutrition infusion pump, stationary | California PPO Prior Authorization List, Pg 66 Original policy |
| C1721 | Cardioverter-defibrillator, dual chamber (implantable) | California PPO Prior Authorization List, Pg 66 Original policy |
| C1722 | Cardioverter-defibrillator, single chamber (implantable) | California PPO Prior Authorization List, Pg 66 Original policy |
| C1735 | Catheter(s), intravascular for renal denervation, radiofrequency, including all single use system components | California PPO Prior Authorization List, Pg 66 Original policy |
| C1736 | Catheter(s), intravascular for renal denervation, ultrasound, including all single use system components | California PPO Prior Authorization List, Pg 66 Original policy |
| C1763 | Connective tissue, non-human (includes synthetic) [when specified as BioBrace Implant] | California PPO Prior Authorization List, Pg 66 Original policy |
| C1767 | Generator, neurostimulator (implantable), nonrechargeable | California PPO Prior Authorization List, Pg 66 Original policy |
| C1772 | Infusion pump, programmable (implantable) | California PPO Prior Authorization List, Pg 66 Original policy |
| C1777 | Lead, cardioverter-defibrillator, endocardial single coil (implantable) | California PPO Prior Authorization List, Pg 66 Original policy |
| C1778 | Lead, neurostimulator (implantable) | California PPO Prior Authorization List, Pg 66 Original policy |
| C1787 | Patient programmer, neurostimulator | California PPO Prior Authorization List, Pg 66 Original policy |
| C1820 | Generator, neurostimulator (implantable), with rechargeable battery and charging system | California PPO Prior Authorization List, Pg 66 Original policy |
| C1821 | Interspinous process distraction device (implantable) | California PPO Prior Authorization List, Pg 66 Original policy |
| C1824 | Generator, cardiac contractility modulation (implantable) | California PPO Prior Authorization List, Pg 66 Original policy |
| C1825 | Generator, neurostimulator (implantable), non-rechargeable with carotid sinus baroreceptor stimulation lead(s) | California PPO Prior Authorization List, Pg 66 Original policy |
| C1833 | Monitor, cardiac, including intracardiac lead and all system components (implantable) | California PPO Prior Authorization List, Pg 66 Original policy |
| C1839 | Iris prosthesis | California PPO Prior Authorization List, Pg 66 Original policy |
| C1882 | Cardioverter-defibrillator, other than single or dual chamber (implantable) | California PPO Prior Authorization List, Pg 66 Original policy |
| C1883 | Adapter/extension, pacing lead or neurostimulator lead (implantable) | California PPO Prior Authorization List, Pg 66 Original policy |
| C1895 | Lead, cardioverter-defibrillator, endocardial dual coil (implantable) | California PPO Prior Authorization List, Pg 67 Original policy |
| C1896 | Lead, cardioverter-defibrillator, other than endocardial single or dual coil (implantable) | California PPO Prior Authorization List, Pg 67 Original policy |
| C2624 | Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components | California PPO Prior Authorization List, Pg 67 Original policy |
| C2626 | Infusion pump, nonprogrammable, temporary (implantable) | California PPO Prior Authorization List, Pg 67 Original policy |
| C7531 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal angioplasty with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation | California PPO Prior Authorization List, Pg 67 Original policy |
| C7534 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with atherectomy, includes angioplasty within the same vessel, when performed with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation | California PPO Prior Authorization List, Pg 67 Original policy |
| C7535 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal stent placement(s), includes angioplasty within the same vessel, when performed, with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation | California PPO Prior Authorization List, Pg 67 Original policy |
| C7538 | Insertion of new or replacement of permanent pacemaker with ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defribrillator or pacemaker pulse generator (e.g., for upgrade to dual chamber system) | California PPO Prior Authorization List, Pg 67 Original policy |
| C7539 | Insertion of new or replacement of permanent pacemaker with atrial and ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (e.g., for upgrade to dual chamber system) | California PPO Prior Authorization List, Pg 67 Original policy |
| C7540 | Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, dual lead system, with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (e.g., for upgrade to dual chamber system) | California PPO Prior Authorization List, Pg 67 Original policy |
| C9354 | Acellular pericardial tissue matrix of non-human origin (Veritas), per square centimeter | California PPO Prior Authorization List, Pg 67 Original policy |
| C9356 | Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector Sheet), per square centimeter | California PPO Prior Authorization List, Pg 67 Original policy |
| C9364 | Porcine implant, Permacol, per square centimeter | California PPO Prior Authorization List, Pg 67 Original policy |
| C9727 | Insertion of implants into the soft palate; minimum of 3 implants | California PPO Prior Authorization List, Pg 67 Original policy |
| C9807 | Nerve stimulator, percutaneous, peripheral (e.g., Sprint peripheral nerve stimulation system), including electrode and all disposable system components, non-opioid medical device | California PPO Prior Authorization List, Pg 67 Original policy |
| C9734 | Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with or without magnetic resonance (MR) guidance | California PPO Prior Authorization List, Pg 67 Original policy |
| D7940 | Osteoplasty, for orthognathic deformities | California PPO Prior Authorization List, Pg 67 Original policy |
| D7941 | Osteotomy - mandibular rami | California PPO Prior Authorization List, Pg 68 Original policy |