Anthem Blue Cross Blue Shield of California prior authorization, page 5
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 |
|---|---|---|
| 55877 | Ablation, irreversible electroporation, prostate, 1 or more tumors, including imaging guidance, percutaneous | California PPO Prior Authorization List, Pg 9 Original policy |
| 55899 | Unlisted procedure, male genital system [when specified as phalloplasty] or [when specified as image-guided focused ultrasound ablation of prostate tissue for non-oncologic indications, such as benign prostatic hyperplasia] or [when specified as intracavernous injection of autologous adipose- derived regenerative cells, e.g., for erectile dysfunction] or [when specified as nanoparticle thermal ablation] or [when specified as histotripsy of prostate tissue] | California PPO Prior Authorization List, Pg 9 Original policy |
| 56800 | Plastic repair of introitus | California PPO Prior Authorization List, Pg 9 Original policy |
| 56805 | Clitoroplasty for intersex state | California PPO Prior Authorization List, Pg 9 Original policy |
| 57291 | Construction of artificial vagina; without graft | California PPO Prior Authorization List, Pg 9 Original policy |
| 57292 | Construction of artificial vagina; with graft | California PPO Prior Authorization List, Pg 9 Original policy |
| 57335 | Vaginoplasty for intersex state | California PPO Prior Authorization List, Pg 9 Original policy |
| 58150 | Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) | California PPO Prior Authorization List, Pg 9 Original policy |
| 58152 | Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (e.g., Marshall- Marchetti-Krantz, Burch) | California PPO Prior Authorization List, Pg 9 Original policy |
| 58180 | Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) | California PPO Prior Authorization List, Pg 9 Original policy |
| 58200 | Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s) | California PPO Prior Authorization List, Pg 9 Original policy |
| 58210 | Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s) | California PPO Prior Authorization List, Pg 9 Original policy |
| 58240 | Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof | California PPO Prior Authorization List, Pg 10 Original policy |
| 58267 | Vaginal hysterectomy, for uterus 250 g or less; with colpo- urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control | California PPO Prior Authorization List, Pg 10 Original policy |
| 58275 | Vaginal hysterectomy, with total or partial vaginectomy | California PPO Prior Authorization List, Pg 10 Original policy |
| 58280 | Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele | California PPO Prior Authorization List, Pg 10 Original policy |
| 58285 | Vaginal hysterectomy, radical (Schauta type operation) | California PPO Prior Authorization List, Pg 10 Original policy |
| 58548 | Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed | California PPO Prior Authorization List, Pg 10 Original policy |
| 58552 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) | California PPO Prior Authorization List, Pg 10 Original policy |
| 58554 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) | California PPO Prior Authorization List, Pg 10 Original policy |
| 58570 | Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less | California PPO Prior Authorization List, Pg 10 Original policy |
| 58571 | Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) | California PPO Prior Authorization List, Pg 10 Original policy |
| 58572 | Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g | California PPO Prior Authorization List, Pg 10 Original policy |
| 58573 | Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) | California PPO Prior Authorization List, Pg 10 Original policy |
| 58578 | Unlisted laparoscopy procedure, uterus [when specified as HALT procedure] | California PPO Prior Authorization List, Pg 10 Original policy |
| 58953 | Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking | California PPO Prior Authorization List, Pg 10 Original policy |
| 58954 | Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy | California PPO Prior Authorization List, Pg 10 Original policy |
| 58956 | Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy | California PPO Prior Authorization List, Pg 10 Original policy |
| 58999 | Unlisted procedure, female genital system (nonobstetrical) [when specified as any vaginal rejuvenation or tightening procedure for atrophy, including laser procedures such as MonaLisa Touch] or [when specified as cancer screening or identification using an optical detection system] or [when specified as image-guided percutaneous ablation by laser, bipolar electrodes, interstitial thermotherapy, cryotherapy, radiofrequency] | California PPO Prior Authorization List, Pg 10 Original policy |
| 59525 | Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 10 Original policy |
| 60699 | Unlisted procedure, endocrine system [when specified as cryosurgical or radiofrequency ablation of thyroid or adrenal tumor(s)] or [when specified as image-guided focused ultrasound ablation for non-oncologic indications] or [when specified as implantation of allogeneic processed thymus tissue-agdc (RETHYMIC)] | California PPO Prior Authorization List, Pg 10 Original policy |
| 61630 | Balloon angioplasty, intracranial (e.g., atherosclerotic stenosis), percutaneous | California PPO Prior Authorization List, Pg 10 Original policy |
| 61635 | Transcatheter placement of intravascular stent(s), intracranial (e.g., atherosclerotic stenosis), including balloon angioplasty, if performed | California PPO Prior Authorization List, Pg 10 Original policy |
| 61736 | Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 simple lesion | California PPO Prior Authorization List, Pg 10 Original policy |
| 61737 | Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; multiple trajectories for multiple or complex lesions | California PPO Prior Authorization List, Pg 10 Original policy |
| 61850 | Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical | California PPO Prior Authorization List, Pg 10 Original policy |
| 61860 | Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical | California PPO Prior Authorization List, Pg 10 Original policy |
| 61863 | Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperattive microelectrode recording | California PPO Prior Authorization List, Pg 11 Original policy |
| 61864 | Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperattive microelectrode recording; each additional array | California PPO Prior Authorization List, Pg 11 Original policy |
| 61867 | Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array | California PPO Prior Authorization List, Pg 11 Original policy |
| 61868 | Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; each additional array | California PPO Prior Authorization List, Pg 11 Original policy |
| 61886 | Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays | California PPO Prior Authorization List, Pg 11 Original policy |
| 61889 | Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, when performed, with direct or inductive coupling, with connection to depth and/or cortical strip electrode array(s) | California PPO Prior Authorization List, Pg 11 Original policy |
| 61891 | Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode array(s) | California PPO Prior Authorization List, Pg 11 Original policy |
| 62331 | Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance (i.e., CT or fluoroscopy), bilateral; additional interspace(s), lumbar | California PPO Prior Authorization List, Pg 11 Original policy |
| 62365 | Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion [when specified as pump removal] | California PPO Prior Authorization List, Pg 11 Original policy |
| 64505 | Injection, anesthetic agent; sphenopalatine ganglion [when specified as a therapeutic nerve block] | California PPO Prior Authorization List, Pg 11 Original policy |
| 64595 | Revision or removal of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array [when specified as sacral nerve stimulator] | California PPO Prior Authorization List, Pg 11 Original policy |
| 64736 | Transection or avulsion of; mental nerve | California PPO Prior Authorization List, Pg 11 Original policy |
| 64738 | Transection or avulsion of; inferior alveolar nerve by osteotomy | California PPO Prior Authorization List, Pg 11 Original policy |