Anthem Blue Cross Blue Shield of California prior authorization, page 48
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 |
|---|---|---|
| 77301 | Intensity Modulated Radiotherapy Plan W/Dose Volume Histograms | California PPO Prior Authorization List, Pg 120 Original policy |
| 77316 | Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s) | California PPO Prior Authorization List, Pg 120 Original policy |
| 77317 | Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2- 12 channels), includes basic dosimetry calculation(s) | California PPO Prior Authorization List, Pg 120 Original policy |
| 77318 | Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) | California PPO Prior Authorization List, Pg 120 Original policy |
| 77338 | Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT | California PPO Prior Authorization List, Pg 120 Original policy |
| 77370 | Special medical radiation physics consultation | California PPO Prior Authorization List, Pg 120 Original policy |
| 77371 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based | California PPO Prior Authorization List, Pg 120 Original policy |
| 77372 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based | California PPO Prior Authorization List, Pg 120 Original policy |
| 77373 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions | California PPO Prior Authorization List, Pg 120 Original policy |
| 77387 | Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed | California PPO Prior Authorization List, Pg 120 Original policy |
| 77402 | Radiation treatment delivery, > 1 MeV; simple | California PPO Prior Authorization List, Pg 120 Original policy |
| 77407 | Radiation treatment delivery, > 1 MeV; intermediate | California PPO Prior Authorization List, Pg 120 Original policy |
| 77412 | Radiation treatment delivery, > 1 MeV; complex | California PPO Prior Authorization List, Pg 121 Original policy |
| 77424 | Intraoperative Radiation Treatment Delivery, X-Ray, Single Treatment Session | California PPO Prior Authorization List, Pg 121 Original policy |
| 77425 | Intraoperative Radiation Treatment Delivery, Electrons, Single Treatment Session | California PPO Prior Authorization List, Pg 121 Original policy |
| 77432 | Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) | California PPO Prior Authorization List, Pg 121 Original policy |
| 77435 | Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions | California PPO Prior Authorization List, Pg 121 Original policy |
| 77436 | Surface radiation therapy, treatment planning & simulation- aided field setting | California PPO Prior Authorization List, Pg 121 Original policy |
| 77437 | Surface radiation therapy, superficial, delivery, <150 kV, per fraction (eg, electronic brachytherapy) | California PPO Prior Authorization List, Pg 121 Original policy |
| 77438 | Surface radiation therapy, orthovoltage, delivery, >150-500 kV, per fraction | California PPO Prior Authorization List, Pg 121 Original policy |
| 77439 | Surface radiation therapy, superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for treatment of cutaneous tumors, per course of treatment | California PPO Prior Authorization List, Pg 121 Original policy |
| 77469 | Intraoperative radiation treatment management | California PPO Prior Authorization List, Pg 121 Original policy |
| 77470 | Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral or endocavitary irradiation) | California PPO Prior Authorization List, Pg 121 Original policy |
| 77520 | Proton treatment delivery; simple without compensation | California PPO Prior Authorization List, Pg 121 Original policy |
| 77522 | Proton treatment delivery; simple with cpmpensation | California PPO Prior Authorization List, Pg 121 Original policy |
| 77523 | Proton treatment delivery; Intermediate | California PPO Prior Authorization List, Pg 121 Original policy |
| 77525 | Proton treatment delivery; complex | California PPO Prior Authorization List, Pg 121 Original policy |
| 77761 | Intracavitary radiation source application; Simple | California PPO Prior Authorization List, Pg 121 Original policy |
| 77762 | Intracavitary radiation source application; intermediate | California PPO Prior Authorization List, Pg 121 Original policy |
| 77763 | Intracavitary radiation source application; complex | California PPO Prior Authorization List, Pg 121 Original policy |
| 77770 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel [when specified as coronary intravascular brachytherapy] | California PPO Prior Authorization List, Pg 121 Original policy |
| 77771 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels [when specified as coronary intravascular brachytherapy] | California PPO Prior Authorization List, Pg 122 Original policy |
| 77772 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels [when specified as coronary intravascular brachytherapy] | California PPO Prior Authorization List, Pg 122 Original policy |
| 77778 | Interstitial radioelement application; complex | California PPO Prior Authorization List, Pg 122 Original policy |
| 77790 | Supervision, handling, loading, radiation source | California PPO Prior Authorization List, Pg 122 Original policy |
| 78429 | Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan | California PPO Prior Authorization List, Pg 122 Original policy |
| 78430 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan | California PPO Prior Authorization List, Pg 122 Original policy |
| 78431 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan | California PPO Prior Authorization List, Pg 122 Original policy |
| 78432 | Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (e.g., myocardial viability) | California PPO Prior Authorization List, Pg 122 Original policy |
| 78433 | Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (e.g., myocardial viability); with concurrently acquired computed tomography transmission scan | California PPO Prior Authorization List, Pg 122 Original policy |
| 78451 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) | California PPO Prior Authorization List, Pg 122 Original policy |
| 78452 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection | California PPO Prior Authorization List, Pg 122 Original policy |
| 78453 | Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) | California PPO Prior Authorization List, Pg 122 Original policy |
| 78454 | Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection | California PPO Prior Authorization List, Pg 122 Original policy |
| 78459 | PET myocardial, metabolic evaluation | California PPO Prior Authorization List, Pg 122 Original policy |
| 78466 | Planar, infarct avid; qualitative or quantitative | California PPO Prior Authorization List, Pg 122 Original policy |
| 78468 | Planar, infarct avid; with ejection fraction by first pass technique | California PPO Prior Authorization List, Pg 122 Original policy |
| 78469 | SPECT, infarct avid; with or without quantification | California PPO Prior Authorization List, Pg 122 Original policy |
| 78472 | Gated equilibrium; planar, single study, wall motion plus ejection fraction | California PPO Prior Authorization List, Pg 123 Original policy |
| 78473 | Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction | California PPO Prior Authorization List, Pg 123 Original policy |