Anthem Blue Cross Blue Shield of California prior authorization, page 54
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 |
|---|---|---|
| 93315 | Echocardiography, transesophageal for congenital cardiac anomalies | California PPO Prior Authorization List, Pg 137 Original policy |
| 93316 | Echocardiography, transesophageal, probe placement only (congenital cardiac anomalies) | California PPO Prior Authorization List, Pg 137 Original policy |
| 93317 | Echocardiography, transesophageal, image acquisition, interpretation and report only (congenital cardiac anomalies) | California PPO Prior Authorization List, Pg 138 Original policy |
| 93350 | Echocardiography, transthoracic during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report | California PPO Prior Authorization List, Pg 138 Original policy |
| 93351 | Echocardiography, transthoracic during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring with physician supervision | California PPO Prior Authorization List, Pg 138 Original policy |
| 93454 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation | California PPO Prior Authorization List, Pg 138 Original policy |
| 93455 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography | California PPO Prior Authorization List, Pg 138 Original policy |
| 93456 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization | California PPO Prior Authorization List, Pg 138 Original policy |
| 93457 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization | California PPO Prior Authorization List, Pg 138 Original policy |
| 93458 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed | California PPO Prior Authorization List, Pg 138 Original policy |
| 93459 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography | California PPO Prior Authorization List, Pg 138 Original policy |
| 93460 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed | California PPO Prior Authorization List, Pg 138 Original policy |
| 93461 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography | California PPO Prior Authorization List, Pg 138 Original policy |
| 93600 | Bundle of His recording | California PPO Prior Authorization List, Pg 138 Original policy |
| 93602 | Intra-atrial recording | California PPO Prior Authorization List, Pg 138 Original policy |
| 93603 | Right ventricular recording | California PPO Prior Authorization List, Pg 138 Original policy |
| 93619 | Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia | California PPO Prior Authorization List, Pg 138 Original policy |
| 93620 | Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording | California PPO Prior Authorization List, Pg 139 Original policy |
| 93624 | Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction of arrhythmia | California PPO Prior Authorization List, Pg 139 Original policy |
| 93650 | Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement | California PPO Prior Authorization List, Pg 139 Original policy |
| 93653 | Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed, with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry | California PPO Prior Authorization List, Pg 139 Original policy |
| 93654 | Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording, and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recordingleft atrial pacing and recording from coronary sinus or left atrium, and HIS bundle recording, when performed; with treatment of ventricular tachycardia or focus of ventricular ectopy including left ventricular pacing and recording, when performed | California PPO Prior Authorization List, Pg 139 Original policy |
| 93656 | Comprehensive electrophysiologic evaluation with transseptal catheterizations, insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, and intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3- dimensional mapping, intracardiac echocardiography with imaging supervision and interpretation, right ventricular pacing/recording, and His bundle recording, when performed | California PPO Prior Authorization List, Pg 139 Original policy |
| 93657 | Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation | California PPO Prior Authorization List, Pg 139 Original policy |
| 93880 | Duplex scan of extracranial arteries; complete bilateral study | California PPO Prior Authorization List, Pg 139 Original policy |
| 93882 | Duplex scan of extracranial arteries; unilateral or limited study | California PPO Prior Authorization List, Pg 139 Original policy |
| 93922 | Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (e.g., for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1- 2 levels, or ankle/ brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2 levels) | California PPO Prior Authorization List, Pg 139 Original policy |
| 93923 | Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (e.g., for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with provocative functional maneuvers (e.g., measurements with postural provocative tests, or measurements with reactive hyperemia) | California PPO Prior Authorization List, Pg 140 Original policy |
| 93924 | Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (i.e., bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study | California PPO Prior Authorization List, Pg 140 Original policy |
| 93925 | Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study | California PPO Prior Authorization List, Pg 140 Original policy |
| 93926 | Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study | California PPO Prior Authorization List, Pg 140 Original policy |
| 93930 | Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study | California PPO Prior Authorization List, Pg 140 Original policy |
| 93931 | Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study | California PPO Prior Authorization List, Pg 140 Original policy |
| 93978 | Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study | California PPO Prior Authorization List, Pg 140 Original policy |
| 93979 | Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study | California PPO Prior Authorization List, Pg 140 Original policy |
| 95782 | Polysomnography; Younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist | California PPO Prior Authorization List, Pg 140 Original policy |
| 95783 | Polysomnography; Younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist | California PPO Prior Authorization List, Pg 140 Original policy |
| 95800 | Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (e.g., by air flow or peripheral arterial tone) and sleep time | California PPO Prior Authorization List, Pg 140 Original policy |
| 95801 | Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (e.g., by air flow or peripheral arterial tone) | California PPO Prior Authorization List, Pg 140 Original policy |
| 95805 | Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness | California PPO Prior Authorization List, Pg 140 Original policy |
| 95806 | Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e.g., thoracoabdominal movement) | California PPO Prior Authorization List, Pg 140 Original policy |
| 95807 | Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist | California PPO Prior Authorization List, Pg 140 Original policy |
| 95808 | Polysomnography; Any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist | California PPO Prior Authorization List, Pg 140 Original policy |
| 95810 | Polysomnography; Age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist | California PPO Prior Authorization List, Pg 141 Original policy |
| 95811 | Polysomnography; Age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist | California PPO Prior Authorization List, Pg 141 Original policy |
| 95921 | Testing of autonomic nervous system function; cardiovagal innervations (parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio | California PPO Prior Authorization List, Pg 141 Original policy |
| 95922 | Testing of autonomic nervous system function; vasomotor adrenergic innervations (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least 5 minutes of passive tilt | California PPO Prior Authorization List, Pg 141 Original policy |
| 95923 | Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential | California PPO Prior Authorization List, Pg 141 Original policy |
| 95924 | Testing of autonomic nervous system function; combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt | California PPO Prior Authorization List, Pg 141 Original policy |
| 95965 | Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (e.g., epileptic cerebral cortex localization) | California PPO Prior Authorization List, Pg 141 Original policy |