Anthem Blue Cross Blue Shield of California prior authorization, page 6
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 |
|---|---|---|
| 64740 | Transection or avulsion of; lingual nerve | California PPO Prior Authorization List, Pg 11 Original policy |
| 64742 | Transection or avulsion of; facial nerve, differential or complete | California PPO Prior Authorization List, Pg 11 Original policy |
| 64787 | Implantation of nerve end into bone or muscle | California PPO Prior Authorization List, Pg 11 Original policy |
| 64864 | Suture of facial nerve; extracranial | California PPO Prior Authorization List, Pg 11 Original policy |
| 64865 | Suture of facial nerve; infratemporal, with or without grafting | California PPO Prior Authorization List, Pg 11 Original policy |
| 64866 | Anastomosis; facial-spinal accessory | California PPO Prior Authorization List, Pg 11 Original policy |
| 64868 | Anastomosis; facial-hypoglossal | California PPO Prior Authorization List, Pg 11 Original policy |
| 64999 | Unlisted procedure, nervous system [when specified as implantation, revision, replacement, or removal of vagus nerve blocking neurostimulator electrode array or pulse generator at the esophagogastric junction] or [when specified as percutaneous neuromodulation therapy] or [when specified as introduction of Kebilidi into cranial cavity and brain] or [when specified as craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebellar] or [when specified as percutaneous decompression or laser procedures of cervical or thoracic spine] or [when specified as epiduroscopy] or [when specified as pulsed radiofrequency treatment] or [when specified as cooled or pulsed RF therapy (not destruction) to genicular nerve(s)] or [when specified as cryoneurolysis] or [when specified as nanoparticle thermal ablation] or [when specified as adrenal tissue, fetal mesencephalic tissue or fetal xenograft tissue transplant to brain] or [when specified as harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | California PPO Prior Authorization List, Pg 11 Original policy |
| 67027 | Implantation of intravitreal drug delivery system (e.g., ganciclovir implant), includes concomitant removal of vitreous [when specified as intravitreal implantation of Encelto (revakinagene taroretcel-lwey) | California PPO Prior Authorization List, Pg 11 Original policy |
| 69090 | Ear piercing | California PPO Prior Authorization List, Pg 12 Original policy |
| 69300 | Otoplasty, protruding ear, with or without size reduction | California PPO Prior Authorization List, Pg 12 Original policy |
| 69399 | Unlisted procedure, external ear [when specified as other otoplasty] | California PPO Prior Authorization List, Pg 12 Original policy |
| 69799 | Unlisted procedure, middle ear [when specified as implantation of semi-implantable or fully implantable hearing aid] or [when specified as balloon dilation of eustachian tube, any approach] | California PPO Prior Authorization List, Pg 12 Original policy |
| 69949 | Unlisted procedure, inner ear [when specified as implantation of hybrid cochlear device] | California PPO Prior Authorization List, Pg 12 Original policy |
| 69955 | Total facial nerve decompression and/or repair (may include graft) | California PPO Prior Authorization List, Pg 12 Original policy |
| 76498 | Unlisted magnetic resonance procedure (e.g., diagnostic, interventional) [when specified as magnetic resonance neurography] | California PPO Prior Authorization List, Pg 12 Original policy |
| 76499 | Unlisted diagnostic radiographic procedure [when specified as 4-D or 5-D rendering of fetal ultrasound] | California PPO Prior Authorization List, Pg 12 Original policy |
| 81490 | Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score | California PPO Prior Authorization List, Pg 12 Original policy |
| 81517 | Liver disease, analysis of 3 biomarkers (hyaluronic acid [HA], procollagen III amino terminal peptide [PIIINP], tissue inhibitor of metalloproteinase 1 [TIMP-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years | California PPO Prior Authorization List, Pg 12 Original policy |
| 81535 | Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination | California PPO Prior Authorization List, Pg 12 Original policy |
| 81536 | Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; each additional single drug or drug combination | California PPO Prior Authorization List, Pg 12 Original policy |
| 81538 | Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival | California PPO Prior Authorization List, Pg 12 Original policy |
| 81560 | Transplantation medicine (allograft rejection, pediatric liver and small bowel), measurement of donor and third-party- induced CD154+T-cytotoxic memory cells, utilizing whole peripheral blood, algorithm reported as a rejection risk score | California PPO Prior Authorization List, Pg 12 Original policy |
| 81596 | Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utilizing serum, prognostic algorithm reported as scores for fibrosis and necroinflammatory activity in liver | California PPO Prior Authorization List, Pg 12 Original policy |
| 81599 | Unlisted multianalyte assay with algorithmic analysis | California PPO Prior Authorization List, Pg 12 Original policy |
| 82233 | Beta-amyloid; 1-40 (Abeta 40) | California PPO Prior Authorization List, Pg 12 Original policy |
| 82234 | Beta-amyloid; 1-42 (Abeta 42) | California PPO Prior Authorization List, Pg 12 Original policy |
| 82542 | Column chromatography, includes mass spectrometry, if performed (e.g., HPLC, LC, LC/MS, LC/MS-MS, GC, GC/MS- MS, GC/MS, HPLC/MS), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen [when specified as testing for PFAS] | California PPO Prior Authorization List, Pg 12 Original policy |
| 82787 | Gammaglobulin (immunoglobulin); immunoglobulin subclasses (e.g., IgG1, 2, 3, or 4), each | California PPO Prior Authorization List, Pg 12 Original policy |
| 83516 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method [when specified as ALCAT or Mediator Release Test (MRT)] | California PPO Prior Authorization List, Pg 12 Original policy |
| 83520 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified or [when specified as testing for food allergy or sensitivity (e.g., IgG testing)] or [when specified as tau protein, amyloid beta peptide testing] | California PPO Prior Authorization List, Pg 12 Original policy |
| 84112 | Evaluation of cervicovaginal fluid for specific amniotic fluid protein(s) (e.g., placental alpha microglobulin-1 [PAMG-1], placental protein 12 [PP12], alpha-fetoprotein), qualitative, each specimen | California PPO Prior Authorization List, Pg 12 Original policy |
| 84999 | Unlisted chemistry procedure | California PPO Prior Authorization List, Pg 13 Original policy |
| 83884 | Neurofilament light chain (NfL) | California PPO Prior Authorization List, Pg 13 Original policy |
| 83921 | Organic acid, single, quantitative [when specified as testing for PFAS] | California PPO Prior Authorization List, Pg 13 Original policy |
| 84393 | Tau, phosphorylated (e.g., pTau 181, pTau 217), each | California PPO Prior Authorization List, Pg 13 Original policy |
| 84394 | Tau, total (tTau) | California PPO Prior Authorization List, Pg 13 Original policy |
| 86001 | Allergen specific IgG quantitative or semiquantitative, each allergen | California PPO Prior Authorization List, Pg 13 Original policy |
| 86343 | Leukocyte histamine release test (LHR) [includes basophil histamine release test] | California PPO Prior Authorization List, Pg 13 Original policy |
| 86352 | Cellular function assay involving stimulation (e.g., mitogen or antigen) and detection of biomarker (e.g., ATP) | California PPO Prior Authorization List, Pg 13 Original policy |
| 86677 | Antibody; Helicobacter pylori | California PPO Prior Authorization List, Pg 13 Original policy |
| 86849 | Unlisted immunology procedure [when specified as in vitro chemosensitivity or in vitro chemoresistance assay, ex vivo analysis of programmed cell death] or [when specified as Complement Antigen Test for delayed food allergy, Mediator Release Test (MRT), or Basophil Activation Test (BAT) by flow cytometry] | California PPO Prior Authorization List, Pg 13 Original policy |
| 87999 | Unlisted microbiology procedure [when specified as in vitro chemosensitivity or in vitro chemoresistance assay] or [when specified as a pooled antibiotic sensitivity test with multiplex PCR, such as the Guidance® UTI test] | California PPO Prior Authorization List, Pg 13 Original policy |
| 88399 | Unlisted surgical pathology procedure [when specified as use of an AI-based software product for cytopathologic prostate cancer detection] | California PPO Prior Authorization List, Pg 13 Original policy |
| 89240 | Unlisted miscellaneous pathology test [when specified as in vitro chemosensitivity or in vitro chemoresistance assay] or [when specified as fecal analysis for intestinal dysbiosis or other intestinal symptoms and disorders] or [when specified as a topographic genotyping test (for example, PancraGEN, BarreGEN, RespriDX tests)] | California PPO Prior Authorization List, Pg 13 Original policy |
| 89398 | Unlisted reproductive medicine laboratory procedure [when specified as a sperm DNA fragmentation test] | California PPO Prior Authorization List, Pg 13 Original policy |
| 90867 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management | California PPO Prior Authorization List, Pg 13 Original policy |
| 90868 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session | California PPO Prior Authorization List, Pg 13 Original policy |
| 90869 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management | California PPO Prior Authorization List, Pg 13 Original policy |
| 90875 | Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (e.g., insight oriented, behavior modifying or supportive psychotherapy); 30 minutes or [when specified as EEG biofeedback or neurofeedback] | California PPO Prior Authorization List, Pg 13 Original policy |