Anthem Blue Cross Blue Shield of California prior authorization, page 35
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 |
|---|---|---|
| 01992 | 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); prone position | California PPO Prior Authorization List, Pg 79 Original policy |
| 11950 | Subcutaneous injection of filling material (e.g., collagen); 1 cc or less | California PPO Prior Authorization List, Pg 79 Original policy |
| 11951 | Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc | California PPO Prior Authorization List, Pg 80 Original policy |
| 11952 | Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc | California PPO Prior Authorization List, Pg 80 Original policy |
| 11954 | Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc | California PPO Prior Authorization List, Pg 80 Original policy |
| 15011 | Harvest of skin for skin cell suspension autograft; first 25 sq cm or less | California PPO Prior Authorization List, Pg 80 Original policy |
| 15012 | Harvest of skin for skin cell suspension autograft; each additional 25 sq cm or part thereof | California PPO Prior Authorization List, Pg 80 Original policy |
| 15013 | Preparation of skin cell suspension autograft, requiring enzymatic processing, manual mechanical disaggregation of skin cells, and filtration; first 25 sq cm or less of harvested skin | California PPO Prior Authorization List, Pg 80 Original policy |
| 15014 | Preparation of skin cell suspension autograft, requiring enzymatic processing, manual mechanical disaggregation of skin cells, and filtration; each additional 25 sq cm of harvested skin or part thereof | California PPO Prior Authorization List, Pg 80 Original policy |
| 15015 | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, trunk, arms, legs; first 480 sq cm or less | California PPO Prior Authorization List, Pg 80 Original policy |
| 15016 | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, trunk, arms, legs; each additional 480 sq cm or part thereof | California PPO Prior Authorization List, Pg 80 Original policy |
| 15017 | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 480 sq cm or less | California PPO Prior Authorization List, Pg 80 Original policy |
| 15018 | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 480 sq cm or part thereof | California PPO Prior Authorization List, Pg 80 Original policy |
| 15771 | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate | California PPO Prior Authorization List, Pg 80 Original policy |
| 15772 | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof | California PPO Prior Authorization List, Pg 80 Original policy |
| 15773 | Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate | California PPO Prior Authorization List, Pg 80 Original policy |
| 15774 | Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof | California PPO Prior Authorization List, Pg 80 Original policy |
| 19296 | Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes image guidance | California PPO Prior Authorization List, Pg 80 Original policy |
| 20555 | Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application | California PPO Prior Authorization List, Pg 80 Original policy |
| 20605 | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa; without ultrasound guidance [only when specified as temporomandibular joint aspiration] | California PPO Prior Authorization List, Pg 80 Original policy |
| 20606 | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa; with ultrasound guidance, with permanent recording and reporting [only when specified as temporomandibular joint aspiration] | California PPO Prior Authorization List, Pg 80 Original policy |
| 20930 | Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 81 Original policy |
| 20931 | Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 81 Original policy |
| 20932 | Allograft, includes templating, cutting, placement and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 81 Original policy |
| 20933 | Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (i.e., hemicylindrical) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 81 Original policy |
| 20934 | Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (i.e., cylindrical) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 81 Original policy |
| 20936 | Autograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 81 Original policy |
| 20937 | Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 81 Original policy |
| 20938 | Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 81 Original policy |
| 20939 | Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 81 Original policy |
| 20974 | Electrical stimulation to aid bone healing; noninvasive (nonoperative) | California PPO Prior Authorization List, Pg 81 Original policy |
| 21010 | Arthrotomy, temporomandibular joint | California PPO Prior Authorization List, Pg 81 Original policy |
| 21050 | Condylectomy, temporomandibular joint (separate procedure) | California PPO Prior Authorization List, Pg 81 Original policy |
| 21060 | Meniscectomy, partial or complete, temporomandibular joint (separate procedure) | California PPO Prior Authorization List, Pg 81 Original policy |
| 21073 | Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e., general or monitored anesthesia care) | California PPO Prior Authorization List, Pg 81 Original policy |
| 21110 | Application of interdental fixation device for conditions other than fracture or dislocation, includes removal | California PPO Prior Authorization List, Pg 81 Original policy |
| 21116 | Injection procedure for temporomandibular joint arthrography | California PPO Prior Authorization List, Pg 81 Original policy |
| 21240 | Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) | California PPO Prior Authorization List, Pg 81 Original policy |
| 21242 | Arthroplasty, temporomandibular joint, with allograft | California PPO Prior Authorization List, Pg 81 Original policy |
| 21243 | Arthroplasty, temporomandibular joint, with prosthetic joint replacement | California PPO Prior Authorization List, Pg 81 Original policy |
| 21811 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs | California PPO Prior Authorization List, Pg 82 Original policy |
| 21812 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs | California PPO Prior Authorization List, Pg 82 Original policy |
| 22206 | Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (e.g., pedicle/vertebral body subtraction); thoracic | California PPO Prior Authorization List, Pg 82 Original policy |
| 22207 | Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (e.g., pedicle/vertebral body subtraction); lumbar | California PPO Prior Authorization List, Pg 82 Original policy |
| 22208 | Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (e.g., pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 82 Original policy |
| 22210 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical | California PPO Prior Authorization List, Pg 82 Original policy |
| 22212 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic | California PPO Prior Authorization List, Pg 82 Original policy |
| 22214 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar | California PPO Prior Authorization List, Pg 82 Original policy |
| 22216 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (List separately in addition to primary procedure) | California PPO Prior Authorization List, Pg 82 Original policy |
| 22220 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical | California PPO Prior Authorization List, Pg 82 Original policy |