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Anthem Blue Cross Blue Shield of California prior authorization, page 47

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
CodeDescriptionSource
73225MR angiography upper extremity; with and w/o contrastCalifornia PPO Prior Authorization List, Pg 117 Original policy
73700CT lower extremity; w/o contrastCalifornia PPO Prior Authorization List, Pg 117 Original policy
73701CT lower extremity; with contrastCalifornia PPO Prior Authorization List, Pg 117 Original policy
73702CT lower extremity; w/o contrast followed by contrastCalifornia PPO Prior Authorization List, Pg 117 Original policy
73706CT angiography lower extremity, with contrast, including non- contrast images, if performedCalifornia PPO Prior Authorization List, Pg 117 Original policy
73718MRI lower extremity, other than joint w/o contrastCalifornia PPO Prior Authorization List, Pg 117 Original policy
73719MRI lower extremity, other than joint w contrastCalifornia PPO Prior Authorization List, Pg 117 Original policy
73720MRI lower extremity, other than joint w/o contrast followed by contrastCalifornia PPO Prior Authorization List, Pg 117 Original policy
73721MRI lower extremity, any joint w/o contrastCalifornia PPO Prior Authorization List, Pg 117 Original policy
73722MRI lower extremity, any joint w contrastCalifornia PPO Prior Authorization List, Pg 117 Original policy
73723MRI lower extremity, any joint w/o contrast followed by contrastCalifornia PPO Prior Authorization List, Pg 117 Original policy
73725MR angiography lower extremity; with or w/o contrastCalifornia PPO Prior Authorization List, Pg 117 Original policy
74150CT abdomen; w/o contrastCalifornia PPO Prior Authorization List, Pg 117 Original policy
74160CT abdomen; with contrastCalifornia PPO Prior Authorization List, Pg 118 Original policy
74170CT abdomen; w/o contrast followed by contrastCalifornia PPO Prior Authorization List, Pg 118 Original policy
74174CT angiography abdomen and pelvis, with contrast, including non-contrast images, if performedCalifornia PPO Prior Authorization List, Pg 118 Original policy
74175CT angiography abdomen, with contrast, including non- contrast images, if performedCalifornia PPO Prior Authorization List, Pg 118 Original policy
74176CT abdomen and pelvis; w/o contrastCalifornia PPO Prior Authorization List, Pg 118 Original policy
74177CT abdomen and pelvis; with contrastCalifornia PPO Prior Authorization List, Pg 118 Original policy
74178CT abdomen and pelvis; w/o contrast followed by contrastCalifornia PPO Prior Authorization List, Pg 118 Original policy
74181MRI abdomen; w/o contrastCalifornia PPO Prior Authorization List, Pg 118 Original policy
74182MRI abdomen; with contrastCalifornia PPO Prior Authorization List, Pg 118 Original policy
74183MRI abdomen; w/o contrast followed by contrastCalifornia PPO Prior Authorization List, Pg 118 Original policy
74185MR angiography abdomen; with or w/o contrastCalifornia PPO Prior Authorization List, Pg 118 Original policy
74261Computed tomographic (CT) colonography, diagnostic, including image post processing; without contrast materialCalifornia PPO Prior Authorization List, Pg 118 Original policy
74262Computed tomographic (CT) colonography, diagnostic, including image post processing; with contrast material(s) including non-contrast images, if performedCalifornia PPO Prior Authorization List, Pg 119 Original policy
74263Computed tomographic (CT) colonography, screening, including image post processingCalifornia PPO Prior Authorization List, Pg 119 Original policy
74712MRI Fetal, including placental and maternal pelvic imaging when performed, single or first gestationCalifornia PPO Prior Authorization List, Pg 119 Original policy
74713MRI fetal, including placental and maternal pelvic imaging when performed, each additional gestationCalifornia PPO Prior Authorization List, Pg 119 Original policy
75557MRI Cardiac for morphology and function without contrast materialCalifornia PPO Prior Authorization List, Pg 119 Original policy
75559MRI Cardiac for morphology and function without contrast material; with stress imagingCalifornia PPO Prior Authorization List, Pg 119 Original policy
75561MRI Cardiac for morphology and function without contrast material(s), followed by contrast material(s) and further sequencesCalifornia PPO Prior Authorization List, Pg 119 Original policy
75563MRI Cardiac for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imagingCalifornia PPO Prior Authorization List, Pg 119 Original policy
75571Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calciumCalifornia PPO Prior Authorization List, Pg 119 Original policy
75572Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image post processing, assessment of cardiac function, and evaluation of venous structures, if performed)California PPO Prior Authorization List, Pg 119 Original policy
75573Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image post processing, assessment of left ventricular cardiac function, right ventricular structure and function and evaluation of venous structures, if performed)California PPO Prior Authorization List, Pg 119 Original policy
75574Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)California PPO Prior Authorization List, Pg 119 Original policy
75580Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of the data set from a coronary computed tomography angiography, with interpretation and report by a physician or other qualified health care professionalCalifornia PPO Prior Authorization List, Pg 119 Original policy
75635CT angiography abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including non- contrast images, if performed, and image post-processingCalifornia PPO Prior Authorization List, Pg 119 Original policy
76390MR SpectroscopyCalifornia PPO Prior Authorization List, Pg 119 Original policy
76391Magnetic resonance (e.g., vibration) elastographyCalifornia PPO Prior Authorization List, Pg 119 Original policy
76873Echography, Transrectal; Prostate Volume Study, Brachytherapy PlanningCalifornia PPO Prior Authorization List, Pg 119 Original policy
76965Ultrasonic guidance for interstitial radioelement applicationCalifornia PPO Prior Authorization List, Pg 119 Original policy
77046Magnetic resonance imaging, breast, without contrast material; unilateralCalifornia PPO Prior Authorization List, Pg 120 Original policy
77047Magnetic resonance imaging, breast, without contrast material; bilateralCalifornia PPO Prior Authorization List, Pg 120 Original policy
77048Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateralCalifornia PPO Prior Authorization List, Pg 120 Original policy
77049Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateralCalifornia PPO Prior Authorization List, Pg 120 Original policy
77078CT bone mineral density study; axial skeletonCalifornia PPO Prior Authorization List, Pg 120 Original policy
77084MRI bone marrow blood supplyCalifornia PPO Prior Authorization List, Pg 120 Original policy
772953-dimensional radiotherapy plan, including dose-volume histogramsCalifornia PPO Prior Authorization List, Pg 120 Original policy

Sources

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The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

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