Anthem Blue Cross Blue Shield of California prior authorization, page 3
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 |
|---|---|---|
| 33933 | Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation | California PPO Prior Authorization List, Pg 5 Original policy |
| 33935 | Heart-lung transplant with recipient cardiectomy- pneumonectomy | California PPO Prior Authorization List, Pg 5 Original policy |
| 33940 | Donor cardiectomy (including cold preservation) | California PPO Prior Authorization List, Pg 5 Original policy |
| 33944 | Backbench standard preparation of cadaver donor heart allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, pulmonary artery, and left atrium for implantation | California PPO Prior Authorization List, Pg 5 Original policy |
| 33945 | Heart transplant, with or without recipient cardiectomy | California PPO Prior Authorization List, Pg 5 Original policy |
| 33975 | Insertion of ventricular assist device; extracorporeal, single ventricle | California PPO Prior Authorization List, Pg 5 Original policy |
| 33976 | Insertion of ventricular assist device; extracorporeal, biventricular | California PPO Prior Authorization List, Pg 5 Original policy |
| 33979 | Insertion of ventricular assist device; implantable intracorporeal, single ventricle | California PPO Prior Authorization List, Pg 5 Original policy |
| 33981 | Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump | California PPO Prior Authorization List, Pg 5 Original policy |
| 33982 | Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass | California PPO Prior Authorization List, Pg 5 Original policy |
| 33983 | Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass | California PPO Prior Authorization List, Pg 5 Original policy |
| 33990 | Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, arterial access only | California PPO Prior Authorization List, Pg 5 Original policy |
| 33991 | Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, both arterial and venous access, with transseptal puncture | California PPO Prior Authorization List, Pg 5 Original policy |
| 33993 | Repositioning of percutaneous right or left heart ventricular assist device with imaging guidance at separate and distinct session from insertion | California PPO Prior Authorization List, Pg 5 Original policy |
| 33995 | Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right heart, venous access only | California PPO Prior Authorization List, Pg 5 Original policy |
| 33999 | Unlisted procedure, cardiac surgery [when specified as percutaneous transmyocardial revascularization] or [when specified as transmyocardial transcatheter closure of ventricular septal defect, with implant, including cardiopulmonary bypass if performed] or [when specified as transcatheter replacement of tricuspid heart valve] or [when specified as autologous cell therapy for damaged myocardium, including harvesting and preparation of cells] or [when specified as use of a portable normothermic organ perfusion system for heart transplantation] | California PPO Prior Authorization List, Pg 5 Original policy |
| 36262 | Removal of implanted intra-arterial infusion pump | California PPO Prior Authorization List, Pg 5 Original policy |
| 37799 | Unlisted procedure, vascular surgery [when specified as percutaneous hepatic perfusion delivery of intra-arterial high dose melphalan HEPZATO] or [when specified as COMPASS protocol, endoluminal cryoablation, or coil embolization of varicose veins] or [when specified as extracorporeal carbon dioxide removal] | California PPO Prior Authorization List, Pg 5 Original policy |
| 38204 | Management of recipient hematopoietic progenitor cell donor search and cell acquisition | California PPO Prior Authorization List, Pg 6 Original policy |
| 38205 | Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic | California PPO Prior Authorization List, Pg 6 Original policy |
| 38206 | Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous | California PPO Prior Authorization List, Pg 6 Original policy |
| 38207 | Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage | California PPO Prior Authorization List, Pg 6 Original policy |
| 38208 | Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor | California PPO Prior Authorization List, Pg 6 Original policy |
| 38209 | Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor | California PPO Prior Authorization List, Pg 6 Original policy |
| 38210 | Transplant preparation of hematopoietic progenitor cells | California PPO Prior Authorization List, Pg 6 Original policy |
| 38211 | Transplant preparation of hematopoietic progenitor cells | California PPO Prior Authorization List, Pg 6 Original policy |
| 38212 | Transplant preparation of hematopoietic progenitor cells | California PPO Prior Authorization List, Pg 6 Original policy |
| 38213 | Transplant preparation of hematopoietic progenitor cells | California PPO Prior Authorization List, Pg 6 Original policy |
| 38214 | Transplant preparation of hematopoietic progenitor cells | California PPO Prior Authorization List, Pg 6 Original policy |
| 38215 | Transplant preparation of hematopoietic progenitor cells | California PPO Prior Authorization List, Pg 6 Original policy |
| 38225 | Chimeric antigen receptor T-cell (CAR-T) therapy; harvesting of blood-derived T lymphocytes for development of genetically modified autologous CAR-T cells, per day [Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta] | California PPO Prior Authorization List, Pg 6 Original policy |
| 38226 | Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-derived T lymphocytes for transportation (e.g., cryopreservation, storage) [Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta] | California PPO Prior Authorization List, Pg 6 Original policy |
| 38227 | Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preparation of CAR-T cells for administration [Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta] | California PPO Prior Authorization List, Pg 6 Original policy |
| 38228 | Chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell administration, autologous [Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta] | California PPO Prior Authorization List, Pg 6 Original policy |
| 38230 | Bone marrow harvesting for transplantation; allogeneic | California PPO Prior Authorization List, Pg 6 Original policy |
| 38232 | Bone marrow harvesting for transplantation; autologous | California PPO Prior Authorization List, Pg 6 Original policy |
| 38240 | Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic transplantation per donor | California PPO Prior Authorization List, Pg 7 Original policy |
| 38241 | Hematopoietic progenitor cell (HPC); autologous transplantation | California PPO Prior Authorization List, Pg 7 Original policy |
| 38243 | Hematopoietic progenitor cell (HPC); HPC boost | California PPO Prior Authorization List, Pg 7 Original policy |
| 38999 | Unlisted procedure, hemic or lymphatic system [when specified as use of an ex-vivo expansion of cord blood stem cell product such as omidubicel (Omisirge)] or [when specified as bone marrow cell therapy or stem cell therapy such as IM, IV or IA for peripheral vascular disease] | California PPO Prior Authorization List, Pg 7 Original policy |
| 42299 | Unlisted procedure, palate, uvula [when specified as any of the following: Cautery-assisted palatal stiffening (CAPSO); Coblation; Palatal implants; Injection snoreplasty; The Pillar™ system] or [when specified as transpalatal advancement pharyngoplasty (TAP)] | California PPO Prior Authorization List, Pg 7 Original policy |
| 43632 | Gastrectomy, partial, distal; with gastrojejunostomy (Billroth II) [when specified as bariatric surgery] | California PPO Prior Authorization List, Pg 7 Original policy |
| 43633 | Gastrectomy, partial, distal; with Roux-en-Y reconstruction [when specified as bariatric surgery] | California PPO Prior Authorization List, Pg 7 Original policy |
| 43644 | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) | California PPO Prior Authorization List, Pg 7 Original policy |
| 43645 | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption | California PPO Prior Authorization List, Pg 7 Original policy |
| 43659 | Unlisted laparoscopy procedure, stomach [when specified as gastric plication (laparoscopic greater curvature plication [LGCP]) with or without gastric banding, sleeve gastroplasty, or mini-gastric bypass procedure] | California PPO Prior Authorization List, Pg 7 Original policy |
| 43771 | Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only | California PPO Prior Authorization List, Pg 7 Original policy |
| 43775 | Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy) | California PPO Prior Authorization List, Pg 7 Original policy |
| 47399 | Unlisted procedure, liver [when specified as histotripsy of nonmalignant lesion of liver] | California PPO Prior Authorization List, Pg 7 Original policy |
| 43843 | Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty | California PPO Prior Authorization List, Pg 7 Original policy |