Anthem Blue Cross Blue Shield of California prior authorization, page 46

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
Code	Description	Source
70553	MRI brain; w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 113 Original policy
70554	Functional MRI brain not requiring physician administration	California PPO Prior Authorization List, Pg 113 Original policy
70555	Functional MRI brain requiring physician administration	California PPO Prior Authorization List, Pg 113 Original policy
71250	CT thorax; w/o contrast	California PPO Prior Authorization List, Pg 113 Original policy
71260	CT thorax; with contrast	California PPO Prior Authorization List, Pg 113 Original policy
71270	CT thorax; w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 113 Original policy
71271	Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s)	California PPO Prior Authorization List, Pg 113 Original policy
71275	CT angiography chest, with contrast, including non-contrast images, if performed	California PPO Prior Authorization List, Pg 114 Original policy
71550	MRI chest; w/o contrast	California PPO Prior Authorization List, Pg 114 Original policy
71551	MRI chest; with contrast	California PPO Prior Authorization List, Pg 114 Original policy
71552	MRI chest; w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 114 Original policy
71555	MR angiography chest; with or w/o contrast	California PPO Prior Authorization List, Pg 114 Original policy
72125	CT cervical spine; w/o contrast	California PPO Prior Authorization List, Pg 114 Original policy
72126	CT cervical spine; with contrast	California PPO Prior Authorization List, Pg 114 Original policy
72127	CT cervical spine; w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 114 Original policy
72128	CT thoracic spine; w/o contrast	California PPO Prior Authorization List, Pg 114 Original policy
72129	CT thoracic spine; with contrast	California PPO Prior Authorization List, Pg 114 Original policy
72130	CT thoracic spine; w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 114 Original policy
72131	CT lumbar spine; w/o contrast	California PPO Prior Authorization List, Pg 114 Original policy
72132	CT lumbar spine; with contrast	California PPO Prior Authorization List, Pg 114 Original policy
72133	CT lumbar spine; w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 114 Original policy
72141	MRI cervical spine; w/o contrast	California PPO Prior Authorization List, Pg 115 Original policy
72142	MRI cervical spine; with contrast	California PPO Prior Authorization List, Pg 115 Original policy
72146	MRI thoracic spine; w/o contrast	California PPO Prior Authorization List, Pg 115 Original policy
72147	MRI thoracic spine; with contrast	California PPO Prior Authorization List, Pg 115 Original policy
72148	MRI lumbar spine; w/o contrast	California PPO Prior Authorization List, Pg 115 Original policy
72149	MRI lumbar spine; with contrast	California PPO Prior Authorization List, Pg 115 Original policy
72156	MRI cervical spine; w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 115 Original policy
72157	MRI thoracic spine; w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 115 Original policy
72158	MRI lumbar spine; w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 115 Original policy
72159	MR angiography spinal canal	California PPO Prior Authorization List, Pg 115 Original policy
72191	CT angiography pelvis, with contrast, including non-contrast images, if performed	California PPO Prior Authorization List, Pg 115 Original policy
72192	CT pelvis; w/o contrast	California PPO Prior Authorization List, Pg 115 Original policy
72193	CT pelvis; with contrast	California PPO Prior Authorization List, Pg 115 Original policy
72194	CT pelvis w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 115 Original policy
72195	MRI pelvis; w/o contrast	California PPO Prior Authorization List, Pg 116 Original policy
72196	MRI pelvis; with contrast	California PPO Prior Authorization List, Pg 116 Original policy
72197	MRI pelvis; w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 116 Original policy
72198	MR angiography pelvis; w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 116 Original policy
72295	Discography, lumbar; radiological supervision and interpretation	California PPO Prior Authorization List, Pg 116 Original policy
73200	CT upper extremity; w/o contrast	California PPO Prior Authorization List, Pg 116 Original policy
73201	CT upper extremity; with contrast	California PPO Prior Authorization List, Pg 116 Original policy
73202	CT upper extremity; w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 116 Original policy
73206	CT angiography upper extremity, with contrast, including non- contrast images, if performed	California PPO Prior Authorization List, Pg 116 Original policy
73218	MRI upper extremity, other than joint w/o contrast	California PPO Prior Authorization List, Pg 116 Original policy
73219	MRI upper extremity, other than joint with contrast	California PPO Prior Authorization List, Pg 116 Original policy
73220	MRI upper extremity, other than joint w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 116 Original policy
73221	MRI upper extremity, any joint w/o contrast	California PPO Prior Authorization List, Pg 116 Original policy
73222	MRI upper extremity, any joint with contrast	California PPO Prior Authorization List, Pg 116 Original policy
73223	MRI upper extremity, any joint w/o contrast followed by contrast	California PPO Prior Authorization List, Pg 117 Original policy

Sources

California PPO Prior Authorization List