Anthem Blue Cross Blue Shield of California prior authorization, page 34
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 |
|---|---|---|
| Q4351 | Enclose TL Matrix, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4352 | Overlay SL Matrix, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4353 | Xceed TL Matrix, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4354 | PalinGen dual-layer membrane and dual-layer PalinGen X- membrane, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4355 | Abiomend Xplus membrane and abiomend Xplus hydromembrane, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4356 | Abiomend membrane and abiomend hydromembrane, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4357 | Xwrap Plus, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4358 | Xwrap Dual, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4359 | Choriply, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4360 | AmchoPlast FD, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4361 | EpiXpress, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4362 | Cygnus Disk, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4363 | Amnio Burgeon Membrane and Hydromembrane, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4364 | Amnio Burgeon Xplus Membrane and Xplus Hydromembrane, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4365 | Amnio Burgeon Dual-Layer Membrane, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4366 | Dual Layer Amnio Burgeon X-Membrane, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4367 | AmnioCore SL, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4431 | PMA skin substitute product, not otherwise specified [when describing a product with no specific code indicated as investigational and not medically necessary] | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4432 | 510(k) skin substitute product, not otherwise specified [when describing a product with no specific code indicated as investigational and not medically necessary] | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4433 | 361 HCT/P skin substitute product, not otherwise specified [when describing a product with no specific code indicated as investigational and not medically necessary] | California PPO Prior Authorization List, Pg 78 Original policy |
| S1091 | Stent, non-coronary, temporary, with delivery system (Propel) | California PPO Prior Authorization List, Pg 78 Original policy |
| S2080 | Laser-assisted uvulopalatoplasty (LAUP) | California PPO Prior Authorization List, Pg 78 Original policy |
| S2117 | Arthroereisis, subtalar | California PPO Prior Authorization List, Pg 78 Original policy |
| S2230 | Implantation of magnetic component of semi- implantable hearing device on ossicles in middle ear | California PPO Prior Authorization List, Pg 78 Original policy |
| S2300 | Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy | California PPO Prior Authorization List, Pg 78 Original policy |
| S2348 | Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar [DISC nucleoplasty] | California PPO Prior Authorization List, Pg 78 Original policy |
| S3900 | Surface electromyography (EMG) | California PPO Prior Authorization List, Pg 78 Original policy |
| S8130 | Interferential current stimulator, 2 channel | California PPO Prior Authorization List, Pg 78 Original policy |
| S8131 | Interferential current stimulator, 4 channel | California PPO Prior Authorization List, Pg 78 Original policy |
| S8930 | Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with the patient | California PPO Prior Authorization List, Pg 78 Original policy |
| S9056 | Coma stimulation, per diem | California PPO Prior Authorization List, Pg 78 Original policy |
| S9364 | Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula, and nursing visits coded separately) per diem | California PPO Prior Authorization List, Pg 78 Original policy |
| S9365 | Home infusion therapy, total parenteral nutrition (TPN); one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula, and nursing visits coded separately) per diem | California PPO Prior Authorization List, Pg 78 Original policy |
| S9366 | Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula, and nursing visits coded separately) per diem | California PPO Prior Authorization List, Pg 78 Original policy |
| S9367 | Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula, and nursing visits coded separately) per diem | California PPO Prior Authorization List, Pg 78 Original policy |
| S9368 | Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula, and nursing visits coded separately) per diem | California PPO Prior Authorization List, Pg 78 Original policy |
| V5095 | Semi-implantable middle ear hearing prosthesis | California PPO Prior Authorization List, Pg 79 Original policy |
| 00170 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified | California PPO Prior Authorization List, Pg 79 Original policy |
| 00731 | Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified | California PPO Prior Authorization List, Pg 79 Original policy |
| 00732 | Anesthesia for upper gastrointestinal endoscopic procedures; endoscopic retrograde cholangiopancreatography [ERCP] | California PPO Prior Authorization List, Pg 79 Original policy |
| 00811 | Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified | California PPO Prior Authorization List, Pg 79 Original policy |
| 00812 | Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified; screening colonoscopy | California PPO Prior Authorization List, Pg 79 Original policy |
| 00813 | Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum | California PPO Prior Authorization List, Pg 79 Original policy |
| 01937 | Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; cervical or thoracic | California PPO Prior Authorization List, Pg 79 Original policy |
| 01938 | Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral | California PPO Prior Authorization List, Pg 79 Original policy |
| 01939 | Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; cervical or thoracic | California PPO Prior Authorization List, Pg 79 Original policy |
| 01940 | Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral | California PPO Prior Authorization List, Pg 79 Original policy |
| 01941 | Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (e.g., kyphoplasty, vertebroplasty) on the spine or spinal cord; cervical or thoracic | California PPO Prior Authorization List, Pg 79 Original policy |
| 01942 | Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (e.g., kyphoplasty, vertebroplasty) on the spine or spinal cord; lumbar or sacral | California PPO Prior Authorization List, Pg 79 Original policy |
| 01991 | Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); other than the prone position | California PPO Prior Authorization List, Pg 79 Original policy |