Anthem Blue Cross Blue Shield of California prior authorization, page 45
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 |
|---|---|---|
| 64495 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 110 Original policy |
| 64566 | Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming | California PPO Prior Authorization List, Pg 110 Original policy |
| 64582 | Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array | California PPO Prior Authorization List, Pg 110 Original policy |
| 64600 | Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch [specified as RF] | California PPO Prior Authorization List, Pg 110 Original policy |
| 64605 | Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale [specified as RF] | California PPO Prior Authorization List, Pg 110 Original policy |
| 64610 | Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring [specified as RF] | California PPO Prior Authorization List, Pg 110 Original policy |
| 64625 | Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography) | California PPO Prior Authorization List, Pg 110 Original policy |
| 64633 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint | California PPO Prior Authorization List, Pg 110 Original policy |
| 64634 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 110 Original policy |
| 64635 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint | California PPO Prior Authorization List, Pg 110 Original policy |
| 64636 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 110 Original policy |
| 65778 | Placement of amniotic membrane on the ocular surface; without sutures | California PPO Prior Authorization List, Pg 110 Original policy |
| 65779 | Placement of amniotic membrane on the ocular surface; single layer, sutured | California PPO Prior Authorization List, Pg 110 Original policy |
| 65780 | Ocular surface reconstruction; amniotic membrane transplantation, multiple layers | California PPO Prior Authorization List, Pg 111 Original policy |
| 67218 | Destruction of localized lesion of retina (e.g., macular edema, tumors), 1 or more sessions; radiation by implantation of source (includes removal of source) | California PPO Prior Authorization List, Pg 111 Original policy |
| 69710 | Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone | California PPO Prior Authorization List, Pg 111 Original policy |
| 69714 | Implantation, osseointegrated implant, skull; with percutaneous attachment to external speech processor | California PPO Prior Authorization List, Pg 111 Original policy |
| 69716 | Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or resulting in removal of less than 100 sq mm surface area of bone deep to the outer cranial cortex | California PPO Prior Authorization List, Pg 111 Original policy |
| 69717 | Replacement (including removal of existing device), osseointegrated implant, skull; with percutaneous attachment to external speech processor | California PPO Prior Authorization List, Pg 111 Original policy |
| 69719 | Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or involving a bony defect less than 100 sq mm surface area of bone deep to the outer cranial cortex | California PPO Prior Authorization List, Pg 111 Original policy |
| 69729 | Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside of the mastoid and resulting in removal of greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex | California PPO Prior Authorization List, Pg 111 Original policy |
| 69730 | Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside the mastoid and involving a bony defect greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex | California PPO Prior Authorization List, Pg 111 Original policy |
| 70336 | MRI temporomandibular joint(s) | California PPO Prior Authorization List, Pg 111 Original policy |
| 70450 | CT head or brain; w/o contrast | California PPO Prior Authorization List, Pg 111 Original policy |
| 70460 | CT head or brain; with contrast | California PPO Prior Authorization List, Pg 111 Original policy |
| 70470 | CT head or brain; w/o contrast followed by contrast | California PPO Prior Authorization List, Pg 111 Original policy |
| 70471 | CT angiography head and neck, with contrast | California PPO Prior Authorization List, Pg 111 Original policy |
| 70473 | Computed tomographic (CT) cerebral perfusion analysis with contrast material(s), including image postprocessing performed without concurrent CT or CT angiography of the same anatomy | California PPO Prior Authorization List, Pg 111 Original policy |
| 70480 | CT orbit, sella or posterior fossa; w/o contrast | California PPO Prior Authorization List, Pg 112 Original policy |
| 70481 | CT orbit, sella or posterior fossa; with contrast | California PPO Prior Authorization List, Pg 112 Original policy |
| 70482 | CT orbit, sella or posterior fossa; w/o contrast followed by contrast | California PPO Prior Authorization List, Pg 112 Original policy |
| 70486 | CT maxillofacial area; w/o contrast | California PPO Prior Authorization List, Pg 112 Original policy |
| 70487 | CT maxillofacial area; with contrast | California PPO Prior Authorization List, Pg 112 Original policy |
| 70488 | CT maxillofacial area; w/o contrast followed by contrast | California PPO Prior Authorization List, Pg 112 Original policy |
| 70490 | CT soft tissue neck; w/o contrast | California PPO Prior Authorization List, Pg 112 Original policy |
| 70491 | CT soft tissue neck; with contrast | California PPO Prior Authorization List, Pg 112 Original policy |
| 70492 | CT soft tissue neck; w/o contrast followed by contrast | California PPO Prior Authorization List, Pg 112 Original policy |
| 70496 | CT angiography head, with contrast, including non-contrast images, if performed | California PPO Prior Authorization List, Pg 112 Original policy |
| 70498 | CT angiography neck, with contrast, including non-contrast images, if performed | California PPO Prior Authorization List, Pg 112 Original policy |
| 70540 | MRI orbit, face and neck; w/o contrast | California PPO Prior Authorization List, Pg 112 Original policy |
| 70542 | MRI orbit, face and neck; with contrast | California PPO Prior Authorization List, Pg 112 Original policy |
| 70543 | MRI orbit, face and neck; w/o contrast followed by contrast | California PPO Prior Authorization List, Pg 112 Original policy |
| 70544 | MR angiography head; w/o contrast | California PPO Prior Authorization List, Pg 112 Original policy |
| 70545 | MR angiography head; with contrast | California PPO Prior Authorization List, Pg 113 Original policy |
| 70546 | MR angiography head; w/o contrast followed by contrast | California PPO Prior Authorization List, Pg 113 Original policy |
| 70547 | MR angiography neck; w/o contrast | California PPO Prior Authorization List, Pg 113 Original policy |
| 70548 | MR angiography neck; with contrast | California PPO Prior Authorization List, Pg 113 Original policy |
| 70549 | MR angiography neck; w/o contrast followed by contrast | California PPO Prior Authorization List, Pg 113 Original policy |
| 70551 | MRI brain; w/o contrast | California PPO Prior Authorization List, Pg 113 Original policy |
| 70552 | MRI brain; with contrast | California PPO Prior Authorization List, Pg 113 Original policy |