Anthem Blue Cross Blue Shield of California prior authorization, page 43
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 |
|---|---|---|
| 55881 | Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging guidance for, and monitoring of, tissue ablation | California PPO Prior Authorization List, Pg 104 Original policy |
| 55882 | Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging guidance for, and monitoring of, tissue ablation; with insertion of transurethral ultrasound transducer for delivery of thermal ultrasound, including suprapubic tube placement and placement of an endorectal cooling device, when performed | California PPO Prior Authorization List, Pg 104 Original policy |
| 55874 | Transperineal placement of biodegradable material, peri- prostatic, single or multiple injection(s), including image guidance, when performed | California PPO Prior Authorization List, Pg 104 Original policy |
| 55920 | Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application | California PPO Prior Authorization List, Pg 104 Original policy |
| 57155 | Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy | California PPO Prior Authorization List, Pg 105 Original policy |
| 57156 | Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy | California PPO Prior Authorization List, Pg 105 Original policy |
| 57240 | Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy | California PPO Prior Authorization List, Pg 105 Original policy |
| 57250 | Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy | California PPO Prior Authorization List, Pg 105 Original policy |
| 57260 | Combined anteroposterior colporrhaphy, including cystourethroscopy | California PPO Prior Authorization List, Pg 105 Original policy |
| 57268 | Repair of enterocele, vaginal approach (separate procedure) | California PPO Prior Authorization List, Pg 105 Original policy |
| 57282 | Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus) | California PPO Prior Authorization List, Pg 105 Original policy |
| 57295 | Revision (including removal) of prosthetic vaginal graft; vaginal approach | California PPO Prior Authorization List, Pg 105 Original policy |
| 57425 | Laparoscopy, surgical, colpopexy (suspension of vaginal apex) | California PPO Prior Authorization List, Pg 105 Original policy |
| 58145 | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach | California PPO Prior Authorization List, Pg 105 Original policy |
| 60660 | Ablation of 1 or more thyroid nodule(s), one lobe or the isthmus, percutaneous, including imaging guidance, radiofrequency | California PPO Prior Authorization List, Pg 105 Original policy |
| 60661 | Ablation of 1 or more thyroid nodule(s), additional lobe, percutaneous, including imaging guidance, radiofrequency | California PPO Prior Authorization List, Pg 105 Original policy |
| 61790 | Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (e.g., alcohol, thermal, electrical, radiofrequency); gasserian ganglion [specified as RF] | California PPO Prior Authorization List, Pg 105 Original policy |
| 61791 | Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (e.g., alcohol, thermal, electrical, radiofrequency); trigeminal medullary tract [specified as RF] | California PPO Prior Authorization List, Pg 105 Original policy |
| 61796 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion | California PPO Prior Authorization List, Pg 105 Original policy |
| 61797 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple | California PPO Prior Authorization List, Pg 105 Original policy |
| 61798 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion | California PPO Prior Authorization List, Pg 105 Original policy |
| 61799 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex | California PPO Prior Authorization List, Pg 105 Original policy |
| 62290 | Injection procedure for discography, each level; lumbar | California PPO Prior Authorization List, Pg 105 Original policy |
| 62320 | Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic | California PPO Prior Authorization List, Pg 106 Original policy |
| 62321 | Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic | California PPO Prior Authorization List, Pg 106 Original policy |
| 62322 | Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral | California PPO Prior Authorization List, Pg 106 Original policy |
| 62323 | Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral | California PPO Prior Authorization List, Pg 106 Original policy |
| 62380 | Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar | California PPO Prior Authorization List, Pg 106 Original policy |
| 63001 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; cervical | California PPO Prior Authorization List, Pg 106 Original policy |
| 63003 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; thoracic | California PPO Prior Authorization List, Pg 106 Original policy |
| 63005 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis | California PPO Prior Authorization List, Pg 106 Original policy |
| 63012 | Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) | California PPO Prior Authorization List, Pg 106 Original policy |
| 63015 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), more than 2 vertebral segments; cervical | California PPO Prior Authorization List, Pg 106 Original policy |
| 63017 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), more than 2 vertebral segments; lumbar | California PPO Prior Authorization List, Pg 106 Original policy |
| 63020 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical | California PPO Prior Authorization List, Pg 106 Original policy |
| 63030 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar | California PPO Prior Authorization List, Pg 106 Original policy |
| 63035 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 106 Original policy |
| 63040 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical | California PPO Prior Authorization List, Pg 106 Original policy |
| 63042 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar | California PPO Prior Authorization List, Pg 106 Original policy |
| 63043 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 106 Original policy |
| 63044 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in additiion to code for primary procedure) | California PPO Prior Authorization List, Pg 106 Original policy |
| 63045 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; cervical | California PPO Prior Authorization List, Pg 107 Original policy |
| 63046 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; thoracic | California PPO Prior Authorization List, Pg 107 Original policy |
| 63047 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; lumbar | California PPO Prior Authorization List, Pg 107 Original policy |
| 63048 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 107 Original policy |
| 63050 | Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments | California PPO Prior Authorization List, Pg 107 Original policy |
| 63051 | Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [e.g., wire, suture, mini-plates], when performed) | California PPO Prior Authorization List, Pg 107 Original policy |
| 63055 | Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc), single segment; thoracic | California PPO Prior Authorization List, Pg 107 Original policy |
| 63056 | Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (e.g., far lateral herniated intervertebral disc) | California PPO Prior Authorization List, Pg 107 Original policy |
| 63057 | Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 107 Original policy |