Anthem Blue Cross Blue Shield of California prior authorization, page 40
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 |
|---|---|---|
| 31574 | Laryngoscopy, flexible; with injection(s) for augmentation (e.g., percutaneous, transoral), unilateral | California PPO Prior Authorization List, Pg 93 Original policy |
| 32701 | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of catheter(s) for intracavitary radioelement application | California PPO Prior Authorization List, Pg 93 Original policy |
| 33206 | Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial | California PPO Prior Authorization List, Pg 93 Original policy |
| 33207 | Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular | California PPO Prior Authorization List, Pg 93 Original policy |
| 33212 | Insertion of pacemaker pulse generator only; single existing single lead | California PPO Prior Authorization List, Pg 93 Original policy |
| 33213 | Insertion of pacemaker pulse generator only; with existing dual leads | California PPO Prior Authorization List, Pg 93 Original policy |
| 33215 | Repositioning of previously implanted transvenous pacemaker or ICD (right atrial or right ventricular) electrode | California PPO Prior Authorization List, Pg 93 Original policy |
| 33218 | Repair of single transvenous electrode, permanent pacemaker or ICD | California PPO Prior Authorization List, Pg 93 Original policy |
| 33220 | Repair of 2 transvenous electrodes for permanent pacemaker or ICD | California PPO Prior Authorization List, Pg 93 Original policy |
| 33222 | Relocation of skin pocket for pacemaker | California PPO Prior Authorization List, Pg 93 Original policy |
| 33227 | Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system | California PPO Prior Authorization List, Pg 93 Original policy |
| 33233 | Removal of permanent pacemaker pulse generator only | California PPO Prior Authorization List, Pg 93 Original policy |
| 33234 | Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular | California PPO Prior Authorization List, Pg 93 Original policy |
| 33235 | Removal of transvenous pacemaker electrode(s); dual lead system | California PPO Prior Authorization List, Pg 93 Original policy |
| 33262 | Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; single lead system | California PPO Prior Authorization List, Pg 94 Original policy |
| 33276 | Insertion of phrenic nerve stimulator system (pulse generator and stimulating lead[s]), including vessel catheterization, all imaging guidance, and pulse generator initial analysis with diagnostic mode activation, when performed | California PPO Prior Authorization List, Pg 94 Original policy |
| 33277 | Insertion of phrenic nerve stimulator transvenous sensing lead | California PPO Prior Authorization List, Pg 94 Original policy |
| 33278 | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; system, including pulse generator and lead(s) | California PPO Prior Authorization List, Pg 94 Original policy |
| 33279 | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) only | California PPO Prior Authorization List, Pg 94 Original policy |
| 33280 | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator only | California PPO Prior Authorization List, Pg 94 Original policy |
| 33281 | Repositioning of phrenic nerve stimulator transvenous lead(s) | California PPO Prior Authorization List, Pg 94 Original policy |
| 33285 | Insertion, subcutaneous cardiac rhythm monitor, including programming | California PPO Prior Authorization List, Pg 94 Original policy |
| 33287 | Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator | California PPO Prior Authorization List, Pg 94 Original policy |
| 33288 | Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) | California PPO Prior Authorization List, Pg 94 Original policy |
| 36465 | Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (e.g., great saphenous vein, accessory saphenous vein) | California PPO Prior Authorization List, Pg 94 Original policy |
| 36466 | Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (e.g., great saphenous vein, accessory saphenous vein), same leg | California PPO Prior Authorization List, Pg 94 Original policy |
| 36468 | Injection(s) of sclerosant for spider veins (telangiectasia); limb or trunk | California PPO Prior Authorization List, Pg 94 Original policy |
| 36470 | Injection of sclerosing solution; single incompetant vein (other than telangiectasia) | California PPO Prior Authorization List, Pg 94 Original policy |
| 36471 | Injection of sclerosing solution; multiple incompetant veins, same leg (other than telangiectasia) | California PPO Prior Authorization List, Pg 94 Original policy |
| 36473 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated | California PPO Prior Authorization List, Pg 94 Original policy |
| 36474 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites | California PPO Prior Authorization List, Pg 94 Original policy |
| 36475 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated | California PPO Prior Authorization List, Pg 94 Original policy |
| 36476 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites | California PPO Prior Authorization List, Pg 95 Original policy |
| 36478 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated | California PPO Prior Authorization List, Pg 95 Original policy |
| 36479 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites | California PPO Prior Authorization List, Pg 95 Original policy |
| 36482 | Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, inclusive of all | California PPO Prior Authorization List, Pg 95 Original policy |
| 36483 | Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated | California PPO Prior Authorization List, Pg 95 Original policy |
| 36511 | Therapeutic apheresis; for white blood cells | California PPO Prior Authorization List, Pg 95 Original policy |
| 36512 | Therapeutic apheresis; for red blood cells [red blood cell exchange] | California PPO Prior Authorization List, Pg 95 Original policy |
| 36513 | Therapeutic apheresis; for platelets | California PPO Prior Authorization List, Pg 95 Original policy |
| 36514 | Therapeutic apheresis; for plasma pheresis | California PPO Prior Authorization List, Pg 95 Original policy |
| 36516 | Therapeutic apheresis; with extracorporeal immunoadsorption, selective adsorption or selective filtration and plasma reinfusion | California PPO Prior Authorization List, Pg 95 Original policy |
| 36901 | Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report | California PPO Prior Authorization List, Pg 95 Original policy |
| 36902 | Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty | California PPO Prior Authorization List, Pg 95 Original policy |
| 36903 | Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow, including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment | California PPO Prior Authorization List, Pg 95 Original policy |
| 36905 | Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty | California PPO Prior Authorization List, Pg 96 Original policy |
| 36906 | Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment | California PPO Prior Authorization List, Pg 96 Original policy |
| 36907 | Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the angioplasty | California PPO Prior Authorization List, Pg 96 Original policy |
| 36908 | Transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the stenting, and all angioplasty in the central dialysis segment | California PPO Prior Authorization List, Pg 96 Original policy |
| 37241 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) [when specified as coil embolization for varicose vein diagnoses] or [as a treatment for pelvic congestion syndrome (PCS), and percutaneous testicular vein embolization for varicocel] | California PPO Prior Authorization List, Pg 96 Original policy |