Anthem Blue Cross Blue Shield of California prior authorization, page 39
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 |
|---|---|---|
| 29826 | Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (i.e., arch) release, when performed (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 90 Original policy |
| 29827 | Arthroscopy, shoulder, surgical; with rotator cuff repair | California PPO Prior Authorization List, Pg 90 Original policy |
| 29828 | Arthroscopy, shoulder, surgical; biceps tenodesis | California PPO Prior Authorization List, Pg 90 Original policy |
| 29860 | Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) | California PPO Prior Authorization List, Pg 90 Original policy |
| 29861 | Arthroscopy, hip, surgical; with removal of loose body or foreign body | California PPO Prior Authorization List, Pg 90 Original policy |
| 29862 | Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum | California PPO Prior Authorization List, Pg 90 Original policy |
| 29863 | Arthroscopy, hip, surgical; with synovectomy | California PPO Prior Authorization List, Pg 90 Original policy |
| 29866 | Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g., mosaicplasty) (includes harvesting of the autograft[s]) | California PPO Prior Authorization List, Pg 91 Original policy |
| 29867 | Arthroscopy, knee, surgical; osteochondral allograft (e.g., mosaicplasty) | California PPO Prior Authorization List, Pg 91 Original policy |
| 29868 | Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral | California PPO Prior Authorization List, Pg 91 Original policy |
| 29870 | Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) | California PPO Prior Authorization List, Pg 91 Original policy |
| 29871 | Arthroscopy, knee, surgical; for infection, lavage and drainage | California PPO Prior Authorization List, Pg 91 Original policy |
| 29873 | Arthroscopy, knee, surgical; with lateral release | California PPO Prior Authorization List, Pg 91 Original policy |
| 29874 | Arthroscopy, knee, surgical; for removal of loose body or foreign body (e.g., osteochondritis dissecans fragmentation, chondral fragmentation) | California PPO Prior Authorization List, Pg 91 Original policy |
| 29875 | Arthroscopy, knee, surgical; synovectomy, limited (e.g., plica or shelf resection) (separate procedure) | California PPO Prior Authorization List, Pg 91 Original policy |
| 29876 | Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (e.g., medial or lateral) | California PPO Prior Authorization List, Pg 91 Original policy |
| 29877 | Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) | California PPO Prior Authorization List, Pg 91 Original policy |
| 29879 | Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture | California PPO Prior Authorization List, Pg 91 Original policy |
| 29880 | Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed | California PPO Prior Authorization List, Pg 91 Original policy |
| 29881 | Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed | California PPO Prior Authorization List, Pg 91 Original policy |
| 29882 | Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) | California PPO Prior Authorization List, Pg 91 Original policy |
| 29883 | Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) | California PPO Prior Authorization List, Pg 91 Original policy |
| 29884 | Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure) | California PPO Prior Authorization List, Pg 91 Original policy |
| 29885 | Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) | California PPO Prior Authorization List, Pg 91 Original policy |
| 29886 | Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion | California PPO Prior Authorization List, Pg 91 Original policy |
| 29887 | Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation | California PPO Prior Authorization List, Pg 91 Original policy |
| 29888 | Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction | California PPO Prior Authorization List, Pg 92 Original policy |
| 29889 | Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction | California PPO Prior Authorization List, Pg 92 Original policy |
| 29892 | Arthroscopically aided repair of large osteochondritis disssecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthoscopy) | California PPO Prior Authorization List, Pg 92 Original policy |
| 29914 | Arthroscopy, hip, surgical; with femoroplasty (i.e., treatment of cam lesion) | California PPO Prior Authorization List, Pg 92 Original policy |
| 29915 | Arthroscopy, hip, surgical; with acetabuloplasty (i.e., treatment of pincer lesion) | California PPO Prior Authorization List, Pg 92 Original policy |
| 29916 | Arthroscopy, hip, surgical; with labral repair | California PPO Prior Authorization List, Pg 92 Original policy |
| 30117 | Excision or destruction (e.g., laser), intranasal lesion, internal approach | California PPO Prior Authorization List, Pg 92 Original policy |
| 31237 | Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [when specified as debridement following sinus surgery] | California PPO Prior Authorization List, Pg 92 Original policy |
| 31242 | Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation, posterior nasal nerve | California PPO Prior Authorization List, Pg 92 Original policy |
| 31243 | Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve | California PPO Prior Authorization List, Pg 92 Original policy |
| 31253 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed | California PPO Prior Authorization List, Pg 92 Original policy |
| 31254 | Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior) | California PPO Prior Authorization List, Pg 92 Original policy |
| 31255 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) | California PPO Prior Authorization List, Pg 92 Original policy |
| 31256 | Nasal/sinus endoscopy, surgical, with maxillary antrostomy | California PPO Prior Authorization List, Pg 92 Original policy |
| 31257 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy | California PPO Prior Authorization List, Pg 92 Original policy |
| 31259 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus | California PPO Prior Authorization List, Pg 92 Original policy |
| 31267 | Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus | California PPO Prior Authorization List, Pg 92 Original policy |
| 31276 | Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed | California PPO Prior Authorization List, Pg 92 Original policy |
| 31287 | Nasal/sinus endoscopy, surgical, with sphenoidotomy | California PPO Prior Authorization List, Pg 92 Original policy |
| 31288 | Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus | California PPO Prior Authorization List, Pg 93 Original policy |
| 31295 | Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); maxillary sinus ostium, transnasal or via canine fossa | California PPO Prior Authorization List, Pg 93 Original policy |
| 31296 | Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal sinus ostium | California PPO Prior Authorization List, Pg 93 Original policy |
| 31297 | Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); sphenoid sinus ostium | California PPO Prior Authorization List, Pg 93 Original policy |
| 31298 | Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal and sphenoid sinus ostia | California PPO Prior Authorization List, Pg 93 Original policy |