Anthem Blue Cross Blue Shield of California prior authorization, page 36
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 |
|---|---|---|
| 22222 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic | California PPO Prior Authorization List, Pg 82 Original policy |
| 22224 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar | California PPO Prior Authorization List, Pg 82 Original policy |
| 22226 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 82 Original policy |
| 22510 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic | California PPO Prior Authorization List, Pg 82 Original policy |
| 22511 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral | California PPO Prior Authorization List, Pg 82 Original policy |
| 22512 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 82 Original policy |
| 22513 | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance | California PPO Prior Authorization List, Pg 82 Original policy |
| 22514 | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance | California PPO Prior Authorization List, Pg 82 Original policy |
| 22515 | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance | California PPO Prior Authorization List, Pg 83 Original policy |
| 22532 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic | California PPO Prior Authorization List, Pg 83 Original policy |
| 22533 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | California PPO Prior Authorization List, Pg 83 Original policy |
| 22534 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 83 Original policy |
| 22551 | Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 | California PPO Prior Authorization List, Pg 83 Original policy |
| 22552 | Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure) | California PPO Prior Authorization List, Pg 83 Original policy |
| 22554 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 | California PPO Prior Authorization List, Pg 83 Original policy |
| 22556 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic | California PPO Prior Authorization List, Pg 83 Original policy |
| 22558 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | California PPO Prior Authorization List, Pg 83 Original policy |
| 22585 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 83 Original policy |
| 22590 | Arthrodesis, posterior technique, craniocervical (occiput-C2) | California PPO Prior Authorization List, Pg 83 Original policy |
| 22595 | Arthrodesis, posterior technique, atlas-axis (C1-C2) | California PPO Prior Authorization List, Pg 83 Original policy |
| 22600 | Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment | California PPO Prior Authorization List, Pg 83 Original policy |
| 22610 | Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed) | California PPO Prior Authorization List, Pg 83 Original policy |
| 22612 | Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) | California PPO Prior Authorization List, Pg 83 Original policy |
| 22614 | Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 83 Original policy |
| 22630 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar | California PPO Prior Authorization List, Pg 83 Original policy |
| 22632 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 83 Original policy |
| 22633 | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar | California PPO Prior Authorization List, Pg 84 Original policy |
| 22634 | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment | California PPO Prior Authorization List, Pg 84 Original policy |
| 22800 | Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments | California PPO Prior Authorization List, Pg 84 Original policy |
| 22802 | Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments | California PPO Prior Authorization List, Pg 84 Original policy |
| 22804 | Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments | California PPO Prior Authorization List, Pg 84 Original policy |
| 22808 | Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments | California PPO Prior Authorization List, Pg 84 Original policy |
| 22810 | Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments | California PPO Prior Authorization List, Pg 84 Original policy |
| 22830 | Exploration of spinal fusion | California PPO Prior Authorization List, Pg 84 Original policy |
| 22840 | Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 84 Original policy |
| 22841 | Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 84 Original policy |
| 22842 | Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 84 Original policy |
| 22843 | Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 84 Original policy |
| 22844 | Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 84 Original policy |
| 22845 | Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 84 Original policy |
| 22846 | Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 84 Original policy |
| 22847 | Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 84 Original policy |
| 22848 | Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 84 Original policy |
| 22849 | Reinsertion of spinal fixation device | California PPO Prior Authorization List, Pg 84 Original policy |
| 22853 | Insertion of interbody biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g., screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to primary procedure) | California PPO Prior Authorization List, Pg 85 Original policy |
| 22854 | Insertion of intervertebral biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g., screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) | California PPO Prior Authorization List, Pg 85 Original policy |
| 22856 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical | California PPO Prior Authorization List, Pg 85 Original policy |
| 22857 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar | California PPO Prior Authorization List, Pg 85 Original policy |
| 22858 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to primary procedure) | California PPO Prior Authorization List, Pg 85 Original policy |
| 22859 | Insertion of intervertebral biomechanical device(s) (e.g., synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 85 Original policy |