Anthem Blue Cross Blue Shield of California prior authorization, page 55
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 |
|---|---|---|
| 95966 | Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, single modality (e.g., sensory, motor, language, or visual cortex localization) | California PPO Prior Authorization List, Pg 141 Original policy |
| 99151 | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age | California PPO Prior Authorization List, Pg 141 Original policy |
| 99152 | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older | California PPO Prior Authorization List, Pg 141 Original policy |
| 99153 | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes of intraservice time | California PPO Prior Authorization List, Pg 141 Original policy |
| 99155 | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age | California PPO Prior Authorization List, Pg 141 Original policy |
| 99156 | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older | California PPO Prior Authorization List, Pg 141 Original policy |
| 99157 | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes of intraservice time | California PPO Prior Authorization List, Pg 141 Original policy |
| 0006M | Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk classifier. Lab tests for alpha-fetoprotein and for mRNA gene expression profiling for 161 genes using fresh tumor tissue from hepatocellular carcinoma. The test also includes an algorithmic analysis using patient data and the lab test results to report a risk classification score. | California PPO Prior Authorization List, Pg 142 Original policy |
| 0007M | Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor disease index | California PPO Prior Authorization List, Pg 142 Original policy |
| 0017M | Oncology (diffuse large B-cell lymphoma [DLBCL]), mRNA, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffin-embedded tissue, algorithm reported as cell of origin | California PPO Prior Authorization List, Pg 142 Original policy |
| 0020M | Oncology (central nervous system), analysis of 30000 DNA methylation loci by methylation array, utilizing DNA extracted from tumor tissue, diagnostic algorithm reported as probability of matching a reference tumor subclass | California PPO Prior Authorization List, Pg 142 Original policy |
| 0095T | Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 142 Original policy |
| 0098T | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 142 Original policy |
| 0200T | Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles | California PPO Prior Authorization List, Pg 142 Original policy |
| 0201T | Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles | California PPO Prior Authorization List, Pg 142 Original policy |
| 0213T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level | California PPO Prior Authorization List, Pg 142 Original policy |
| 0214T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 142 Original policy |
| 0215T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 142 Original policy |
| 0216T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level | California PPO Prior Authorization List, Pg 142 Original policy |
| 0217T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 142 Original policy |
| 0228T | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level | California PPO Prior Authorization List, Pg 142 Original policy |
| 0229T | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 142 Original policy |
| 0230T | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level | California PPO Prior Authorization List, Pg 142 Original policy |
| 0231T | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 142 Original policy |
| 0342T | Therapeutic apheresis with selective HDL delipidation and plasma reinfusion | California PPO Prior Authorization List, Pg 142 Original policy |
| 0402T | Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed) | California PPO Prior Authorization List, Pg 143 Original policy |
| 0524T | Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging, imaging guidance and monitoring | California PPO Prior Authorization List, Pg 143 Original policy |
| 0571T | Insertion or replacement of implantable cardioverter- defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed | California PPO Prior Authorization List, Pg 143 Original policy |
| 0572T | Insertion of substernal implantable defibrillator electrode | California PPO Prior Authorization List, Pg 143 Original policy |
| 0573T | Removal of substernal implantable defibrillator electrode | California PPO Prior Authorization List, Pg 143 Original policy |
| 0574T | Repositioning of previously implanted substernal implantable defibrillator-pacing electrode | California PPO Prior Authorization List, Pg 143 Original policy |
| 0580T | Removal of substernal implantable defibrillator pulse generator only | California PPO Prior Authorization List, Pg 143 Original policy |
| 0596T | Temporary female intraurethral valve-pump (i.e., voiding prosthesis); initial insertion, including urethral measurement [inFlow system] | California PPO Prior Authorization List, Pg 143 Original policy |
| 0597T | Temporary female intraurethral valve-pump (i.e., voiding prosthesis); replacement [inFlow system] | California PPO Prior Authorization List, Pg 143 Original policy |
| 0614T | Removal and replacement of substernal implantable defibrillator pulse generator | California PPO Prior Authorization List, Pg 143 Original policy |
| 0627T | Percutaneous injection of allogeneic cellular and/or tissue- based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level | California PPO Prior Authorization List, Pg 143 Original policy |
| 0628T | Percutaneous injection of allogeneic cellular and/or tissue- based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; each additional level | California PPO Prior Authorization List, Pg 143 Original policy |
| 0629T | Percutaneous injection of allogeneic cellular and/or tissue- based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level | California PPO Prior Authorization List, Pg 143 Original policy |
| 0630T | Percutaneous injection of allogeneic cellular and/or tissue- based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; each additional level | California PPO Prior Authorization List, Pg 143 Original policy |
| 0633T | CT Breast w/3d rendering uni without contrast | California PPO Prior Authorization List, Pg 143 Original policy |
| 0634T | CT Breast w/3d rendering uni with contrast | California PPO Prior Authorization List, Pg 143 Original policy |
| 0635T | CT Brst w/3d rendering uni wo cntrst flwd cntrst | California PPO Prior Authorization List, Pg 143 Original policy |
| 0636T | CT Breast w/3d rendering bi without contrast | California PPO Prior Authorization List, Pg 143 Original policy |
| 0637T | CT Breast w/3d rendering bi with contrast | California PPO Prior Authorization List, Pg 144 Original policy |
| 0638T | CT Brst w/3d rendering bi wo cntrst flwd cntrst | California PPO Prior Authorization List, Pg 144 Original policy |
| 0648T | Quantitative magnetic resonance for analysis of tissue composition (e.g., fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the same anatomy (e.g., organ, gland, tissue, target structure) during the same session | California PPO Prior Authorization List, Pg 144 Original policy |
| 0649T | Quantitative magnetic resonance for analysis of tissue composition (e.g., fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the same anatomy (e.g., organ, gland, tissue, target structure) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 144 Original policy |
| 0652T | Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | California PPO Prior Authorization List, Pg 144 Original policy |
| 0653T | Esophagogastroduodenoscopy, flexible, transnasal; with biopsy, single or multiple | California PPO Prior Authorization List, Pg 144 Original policy |
| 0654T | Esophagogastroduodenoscopy, flexible, transnasal; with insertion of intraluminal tube or catheter | California PPO Prior Authorization List, Pg 144 Original policy |