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Anthem Blue Cross Blue Shield of California prior authorization, page 4

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
43845Gastric restrictive procedure with partial gastrectomy, pylorus- preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)California PPO Prior Authorization List, Pg 7 Original policy
43846Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomyCalifornia PPO Prior Authorization List, Pg 7 Original policy
43847Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorptionCalifornia PPO Prior Authorization List, Pg 7 Original policy
43848Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)California PPO Prior Authorization List, Pg 7 Original policy
44132Donor enterectomy (including cold preservation), open; from cadaver donorCalifornia PPO Prior Authorization List, Pg 7 Original policy
44133Donor enterectomy (including cold preservation), open; partial, from living donorCalifornia PPO Prior Authorization List, Pg 8 Original policy
44135Intestinal allotransplantation; from cadaver donorCalifornia PPO Prior Authorization List, Pg 8 Original policy
44136Intestinal allotransplantation; from living donorCalifornia PPO Prior Authorization List, Pg 8 Original policy
44715Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and veinCalifornia PPO Prior Authorization List, Pg 8 Original policy
44720Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, eachCalifornia PPO Prior Authorization List, Pg 8 Original policy
44721Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, eachCalifornia PPO Prior Authorization List, Pg 8 Original policy
46999Unlisted procedure, anus [when specified as perianal injection of autologous adipose-derived regenerative cells, e.g., for fistulizing Crohn’s disease] or [when specified as delivery of thermal energy to the muscle of the anal canal (e.g., for fecal incontinence)] or [when specified as anal sphincteroplasty for incontinence with implantation of an artificial sphincter]California PPO Prior Authorization List, Pg 8 Original policy
47133Donor hepatectomy, (including cold preservation), from cadaver donorCalifornia PPO Prior Authorization List, Pg 8 Original policy
47135Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any ageCalifornia PPO Prior Authorization List, Pg 8 Original policy
47140Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III)California PPO Prior Authorization List, Pg 8 Original policy
47141Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III, IV)California PPO Prior Authorization List, Pg 8 Original policy
47142Donor hepatectomy (including cold preservation), from living donor; total right lobectomy (segments V, VI, VII and VIII)California PPO Prior Authorization List, Pg 8 Original policy
47143Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe splitCalifornia PPO Prior Authorization List, Pg 8 Original policy
47144Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with trisegment split of whole liver graft into 2 partial liver grafts (i.e., left lateral segment [segments II and III] and right trisegment [segments I and IV through VIII])California PPO Prior Authorization List, Pg 8 Original policy
47145Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with lobe split of whole liver graft into 2 partial liver grafts (i.e., left lobe [segments II, III, and IV] and right lobe [segments I and V through VIII])California PPO Prior Authorization List, Pg 8 Original policy
47146Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, eachCalifornia PPO Prior Authorization List, Pg 8 Original policy
47147Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, eachCalifornia PPO Prior Authorization List, Pg 8 Original policy
47370Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequencyCalifornia PPO Prior Authorization List, Pg 8 Original policy
47371Laparoscopy, surgical, ablation of 1 or more liver tumor(s); cryosurgicalCalifornia PPO Prior Authorization List, Pg 8 Original policy
47380Ablation, open, of 1 or more liver tumor(s); radiofrequencyCalifornia PPO Prior Authorization List, Pg 8 Original policy
47381Ablation, open, of 1 or more liver tumor(s); cryosurgicalCalifornia PPO Prior Authorization List, Pg 8 Original policy
47382Ablation, 1 or more liver tumor(s), percutaneous, radiofrequencyCalifornia PPO Prior Authorization List, Pg 8 Original policy
47383Ablation, 1 or more liver tumor(s), percutaneous, cryoablationCalifornia PPO Prior Authorization List, Pg 8 Original policy
47384Ablation, irreversible electroporation, liver, 1 or more tumors, including imaging guidance, percutaneousCalifornia PPO Prior Authorization List, Pg 8 Original policy
48160Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cellsCalifornia PPO Prior Authorization List, Pg 8 Original policy
48550Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantationCalifornia PPO Prior Authorization List, Pg 8 Original policy
48551Backbench standard preparation of cadaver donor pancreas allograftCalifornia PPO Prior Authorization List, Pg 8 Original policy
48552Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, eachCalifornia PPO Prior Authorization List, Pg 8 Original policy
48554Transplantation of pancreatic allograftCalifornia PPO Prior Authorization List, Pg 8 Original policy
48556Removal of transplanted pancreatic allograftCalifornia PPO Prior Authorization List, Pg 8 Original policy
48999Unlisted procedure, pancreas [when specified as cryosurgical or radiofrequency ablation of pancreas tumor(s)]California PPO Prior Authorization List, Pg 9 Original policy
50250Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound, if performedCalifornia PPO Prior Authorization List, Pg 9 Original policy
50300Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateralCalifornia PPO Prior Authorization List, Pg 9 Original policy
50320Donor nephrectomy (including cold preservation); open, from living donorCalifornia PPO Prior Authorization List, Pg 9 Original policy
50323Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessaryCalifornia PPO Prior Authorization List, Pg 9 Original policy
50325Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessaryCalifornia PPO Prior Authorization List, Pg 9 Original policy
50327Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, eachCalifornia PPO Prior Authorization List, Pg 9 Original policy
50328Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, eachCalifornia PPO Prior Authorization List, Pg 9 Original policy
50329Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, eachCalifornia PPO Prior Authorization List, Pg 9 Original policy
50340Recipient nephrectomy (separate procedure)California PPO Prior Authorization List, Pg 9 Original policy
50360Renal allotransplantation, implantation of graft; without recipient nephrectomyCalifornia PPO Prior Authorization List, Pg 9 Original policy
50365Renal allotransplantation, implantation of graft; with recipient nephrectomyCalifornia PPO Prior Authorization List, Pg 9 Original policy
50547Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donorCalifornia PPO Prior Authorization List, Pg 9 Original policy
53899Unlisted procedure, urinary system [when specified as transurethral MRI directional ultrasound ablation of prostate tissue (TULSA)] or [when specified as use of a portable normothermic organ perfusion system for kidney transplantation]California PPO Prior Authorization List, Pg 9 Original policy
54440Plastic operation of penis for injuryCalifornia PPO Prior Authorization List, Pg 9 Original policy

Sources

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