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Anthem Blue Cross Blue Shield of California prior authorization, page 30

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
D7943Osteotomy - mandibular rami with bone graft; includes obtaining the graftCalifornia PPO Prior Authorization List, Pg 68 Original policy
D7944Osteotomy-segmented or subapicalCalifornia PPO Prior Authorization List, Pg 68 Original policy
D7945Osteotomy, body of mandibleCalifornia PPO Prior Authorization List, Pg 68 Original policy
D7946LeFort I (maxilla, total)California PPO Prior Authorization List, Pg 68 Original policy
D7947LeFort I (maxilla, segmented)California PPO Prior Authorization List, Pg 68 Original policy
D7948LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion), without bone graftCalifornia PPO Prior Authorization List, Pg 68 Original policy
D7949LeFort II or LeFort III, with bone graftCalifornia PPO Prior Authorization List, Pg 68 Original policy
D7950Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla, autogenous or nonautogenous, by reportCalifornia PPO Prior Authorization List, Pg 68 Original policy
D7995Synthetic graft, mandible or facial bones, by reportCalifornia PPO Prior Authorization List, Pg 68 Original policy
D7996Implant, mandible for augmentation purposes (excluding alveolar ridge), by reportCalifornia PPO Prior Authorization List, Pg 68 Original policy
E0735Non-invasive vagus nerve stimulatorCalifornia PPO Prior Authorization List, Pg 68 Original policy
E0732Cranial electrotherapy stimulation (CES) system, any typeCalifornia PPO Prior Authorization List, Pg 68 Original policy
E1905Virtual reality cognitive behavioral therapy device (CBT), including pre-programmed therapy software [for example, RelieVRx]California PPO Prior Authorization List, Pg 68 Original policy
G0255Current perception threshold/sensory nerve conduction test (SNCT), per limb, any nerveCalifornia PPO Prior Authorization List, Pg 68 Original policy
G0277Hyperbaric oxygen under pressure, full body chamber, per 30 minute intervalCalifornia PPO Prior Authorization List, Pg 68 Original policy
G0428Collagen meniscus implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex)California PPO Prior Authorization List, Pg 69 Original policy
G0448Insertion or replacement of a permanent pacing cardioverter- defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac venous system, for left ventricular pacingCalifornia PPO Prior Authorization List, Pg 69 Original policy
J2779Injection, ranibizumab, via intravitreal implant (Susvimo), 0.1 mgCalifornia PPO Prior Authorization List, Pg 69 Original policy
J7402Mometasone furoate sinus implant, (SINUVA), 10 microgramsCalifornia PPO Prior Authorization List, Pg 69 Original policy
K1030External recharging system for battery (internal) for use with implanted cardiac contractility modulation generator, replacement onlyCalifornia PPO Prior Authorization List, Pg 69 Original policy
L8614Cochlear device, includes all internal and external componentsCalifornia PPO Prior Authorization List, Pg 69 Original policy
L8619Cochlear implant external speech processor, replacementCalifornia PPO Prior Authorization List, Pg 69 Original policy
L8627Cochlear implant, external speech processor, component, replacementCalifornia PPO Prior Authorization List, Pg 69 Original policy
L8628Cochlear implant, external controller component, replacementCalifornia PPO Prior Authorization List, Pg 69 Original policy
L8678Electrical stimulator supplies (external) for use with implantable neurostimulator, per monthCalifornia PPO Prior Authorization List, Pg 69 Original policy
L8679Neurostimulator Implantation - Implantable neurostimulator, pulse generator, any typeCalifornia PPO Prior Authorization List, Pg 69 Original policy
L8680Neurostimulator Implantation - Implantable heurostimulator electrode, eachCalifornia PPO Prior Authorization List, Pg 69 Original policy
L8681Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement onlyCalifornia PPO Prior Authorization List, Pg 69 Original policy
L8682Implantable neurostimulator radiofrequency receiverCalifornia PPO Prior Authorization List, Pg 69 Original policy
L8683Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiverCalifornia PPO Prior Authorization List, Pg 69 Original policy
L8685Implantable neurostimulator pulse generator, single array, rechargeable, includes extensionCalifornia PPO Prior Authorization List, Pg 69 Original policy
L8686Implantable neurostimulator pulse generator, single array, non- rechargeable, includes extensionCalifornia PPO Prior Authorization List, Pg 70 Original policy
L8687Implantable neurostimulator pulse generator, dual array, rechargeable, includes extensionCalifornia PPO Prior Authorization List, Pg 70 Original policy
L8688Implantable neurostimulator pulse generator, dual array, non- rechargeable, includes extensionCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4103Oasis Burn Matrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4108Integra Matrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4111Gammagraft, per square centimeterCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4114Integra Flowable Wound Matrix, injectable, 1 ccCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4117Hyalomatrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4118Matristem micromatrix, 1 mgCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4123AlloSkin RT, per square centimeterCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4125ArthroFlex, per square centimeterCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4126Memoderm, dermaspan, tranzgraft or integuply, per square centimeterCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4127Talymed, per square centimeterCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4132Grafix CORE and GrafixPL CORE, per square centimeterCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4134hMatrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4135Mediskin, per square centimeterCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4137AmnioExCel, AmnioExCel plus or BioDExCel, per square centimeterCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4138BioDfence Dryflex, per square centimeterCalifornia PPO Prior Authorization List, Pg 70 Original policy
Q4139AmnioMatrix or BioDMatrix, injectable, 1 ccCalifornia PPO Prior Authorization List, Pg 70 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.

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