Anthem Blue Cross Blue Shield of California prior authorization, page 44
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 |
|---|---|---|
| 63075 | Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace | California PPO Prior Authorization List, Pg 107 Original policy |
| 63076 | Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 107 Original policy |
| 63081 | Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment | California PPO Prior Authorization List, Pg 107 Original policy |
| 63082 | Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 107 Original policy |
| 63085 | Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment | California PPO Prior Authorization List, Pg 107 Original policy |
| 63086 | Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 107 Original policy |
| 63087 | Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment | California PPO Prior Authorization List, Pg 107 Original policy |
| 63088 | Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; each additional segment (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 107 Original policy |
| 63090 | Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment | California PPO Prior Authorization List, Pg 108 Original policy |
| 63091 | Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 108 Original policy |
| 63101 | Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (e.g., for tumor or retropulsed bone fragments); thoracic, single segment | California PPO Prior Authorization List, Pg 108 Original policy |
| 63102 | Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (e.g., for tumor or retropulsed bone fragments); lumbar, single segment | California PPO Prior Authorization List, Pg 108 Original policy |
| 63103 | Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (e.g., for tumor or retropulsed bone fragments); thoracic or lumbar, each additional segment (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 108 Original policy |
| 63180 | Laminectomy and section of dentate ligaments, with or without dural graft, cervical; 1 or 2 segments | California PPO Prior Authorization List, Pg 108 Original policy |
| 63182 | Laminectomy and section of dentate ligaments, with or without dural graft, cervical; more than 2 segments | California PPO Prior Authorization List, Pg 108 Original policy |
| 63185 | Laminectomy with rhizotomy; more than 2 segments | California PPO Prior Authorization List, Pg 108 Original policy |
| 63190 | Laminectomy, with release of tethered spinal cord, lumbar | California PPO Prior Authorization List, Pg 108 Original policy |
| 63200 | Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar | California PPO Prior Authorization List, Pg 108 Original policy |
| 63252 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar | California PPO Prior Authorization List, Pg 108 Original policy |
| 63265 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical | California PPO Prior Authorization List, Pg 108 Original policy |
| 63267 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar | California PPO Prior Authorization List, Pg 108 Original policy |
| 63270 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical | California PPO Prior Authorization List, Pg 108 Original policy |
| 63272 | Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar | California PPO Prior Authorization List, Pg 108 Original policy |
| 63275 | Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical | California PPO Prior Authorization List, Pg 108 Original policy |
| 63277 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar | California PPO Prior Authorization List, Pg 108 Original policy |
| 63280 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical | California PPO Prior Authorization List, Pg 108 Original policy |
| 63282 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar | California PPO Prior Authorization List, Pg 109 Original policy |
| 63285 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical | California PPO Prior Authorization List, Pg 109 Original policy |
| 63287 | Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level | California PPO Prior Authorization List, Pg 109 Original policy |
| 63290 | Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level | California PPO Prior Authorization List, Pg 109 Original policy |
| 63300 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical | California PPO Prior Authorization List, Pg 109 Original policy |
| 63307 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach | California PPO Prior Authorization List, Pg 109 Original policy |
| 63308 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; each additional segment (List separately in addition to codes for single segment) | California PPO Prior Authorization List, Pg 109 Original policy |
| 63620 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion | California PPO Prior Authorization List, Pg 109 Original policy |
| 63621 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion | California PPO Prior Authorization List, Pg 109 Original policy |
| 63650 | Percutaneous implantation of neurostimulator electrode array, epidural | California PPO Prior Authorization List, Pg 109 Original policy |
| 63655 | Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural | California PPO Prior Authorization List, Pg 109 Original policy |
| 63663 | Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed | California PPO Prior Authorization List, Pg 109 Original policy |
| 63664 | Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed | California PPO Prior Authorization List, Pg 109 Original policy |
| 63685 | Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling | California PPO Prior Authorization List, Pg 109 Original policy |
| 63688 | Revision or removal of implanted spinal neurostimulator pulse generator or receiver | California PPO Prior Authorization List, Pg 109 Original policy |
| 64479 | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level | California PPO Prior Authorization List, Pg 109 Original policy |
| 64480 | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 109 Original policy |
| 64483 | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level | California PPO Prior Authorization List, Pg 109 Original policy |
| 64484 | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 109 Original policy |
| 64490 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level | California PPO Prior Authorization List, Pg 110 Original policy |
| 64491 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 110 Original policy |
| 64492 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 110 Original policy |
| 64493 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level | California PPO Prior Authorization List, Pg 110 Original policy |
| 64494 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 110 Original policy |