Anthem Blue Cross Blue Shield of California prior authorization, page 60
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 |
|---|---|---|
| A9616 | Gallium ga-68 gozetotide (Gozelix) | California PPO Prior Authorization List, Pg 157 Original policy |
| A9800 | Gallium ga-68 gozetotide, diagnostic, (locametz), 1 millicurie (Locametz) | California PPO Prior Authorization List, Pg 157 Original policy |
| A9607 | Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 mCi (Pluvicto) | California PPO Prior Authorization List, Pg 158 Original policy |
| C1605 | Pacemaker, leadless, dual chamber (right atrial and right ventricular implantable components), rate-responsive, including all necessary components for implantation | California PPO Prior Authorization List, Pg 158 Original policy |
| C1607 | Neurostimulator, integrated (implantable), rechargeable with all implantable and external components including charging system | California PPO Prior Authorization List, Pg 158 Original policy |
| C1726 | Catheter, balloon dilatation, non-vascular [when specified as a balloon sinus ostial dilation device] or [when specified as a balloon dilation device used for EGD dilation] | California PPO Prior Authorization List, Pg 158 Original policy |
| C1764 | Event recorder, cardiac (implantable) | California PPO Prior Authorization List, Pg 158 Original policy |
| C1785 | Pacemaker, dual-chamber, rate-responsive (implantable) | California PPO Prior Authorization List, Pg 158 Original policy |
| C1786 | Pacemaker, single-chamber, rate-responsive (implantable) | California PPO Prior Authorization List, Pg 158 Original policy |
| C1813 | Prosthesis, penile, inflatable | California PPO Prior Authorization List, Pg 158 Original policy |
| C1815 | Prosthesis, urinary sphincter (implantable) | California PPO Prior Authorization List, Pg 158 Original policy |
| C1816 | Receiver and/or transmitter, neurostimulator (implantable) [for phrenic nerve stimulator] | California PPO Prior Authorization List, Pg 158 Original policy |
| C1822 | Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system | California PPO Prior Authorization List, Pg 158 Original policy |
| C1823 | Generator; neurostimulator (implantable), non-rechargeable, with transvenous sensing and stimulation leads | California PPO Prior Authorization List, Pg 158 Original policy |
| C1832 | Autograft suspension, including cell processing and application, and all system components | California PPO Prior Authorization List, Pg 158 Original policy |
| C1878 | Material for vocal cord medialization, synthetic (implantable) [e.g., RenuVoice, RenuGel] | California PPO Prior Authorization List, Pg 158 Original policy |
| C2619 | Pacemaker, dual-chamber, non-rate-responsive (implantable) | California PPO Prior Authorization List, Pg 158 Original policy |
| C2621 | Pacemaker, other than single or dual chamber (implantable) | California PPO Prior Authorization List, Pg 158 Original policy |
| C2622 | Prosthesis, penile, non-inflatable | California PPO Prior Authorization List, Pg 158 Original policy |
| C7513 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, with transluminal balloon angioplasty of central dialysis segment, performed through dialysis circuit, including all required imaging, radiological supervision and interpretation, image documentation and report | California PPO Prior Authorization List, Pg 158 Original policy |
| C7514 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, with all angioplasty in the central dialysis segment, and transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all required imaging, radiological supervision and interpretation, image documentation and report | California PPO Prior Authorization List, Pg 159 Original policy |
| C7515 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, with dialysis circuit permanent endovascular embolization or occlusion of main circuit or any accessory veins, including all required imaging, radiological supervision and interpretation, image documentation and report | California PPO Prior Authorization List, Pg 159 Original policy |
| C7517 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, with iliac and/or femoral artery angiography, non-selective, bilateral or ipsilateral to catheter insertion, performed at the same time as cardiac catheterization and/or coronary angiography, includes positioning or placement of the catheter in the distal aorta or ipsilateral femoral or iliac artery, injection of dye, production of permanent images, and radiologic supervision and interpretation | California PPO Prior Authorization List, Pg 159 Original policy |
| C7552 | 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 with intravascular doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress, initial vessel | California PPO Prior Authorization List, Pg 159 Original policy |
| C7553 | 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 with pharmacologic agent administration (e.g., inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after and repeat pharmacologic agent administration, when performed | California PPO Prior Authorization List, Pg 159 Original policy |
| C7568 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation with intraprocedural coronary fractional flow reserve (ffr) with 3d functional mapping of color-coded ffr values for the coronary tree, derived from coronary angiogram data, for real- time review and interpretation of possible atherosclerotic stenosis(es) intervention (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 159 Original policy |
| C7569 | Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with endoluminal imaging of initial coronary vessel or graft using intravascular ultrasound (ivus) or optical coherence tomography (oct) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report | California PPO Prior Authorization List, Pg 159 Original policy |
| C7571 | Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with percutaneous transluminal coronary lithotripsy | California PPO Prior Authorization List, Pg 159 Original policy |
| C8002 | Preparation of skin cell suspension autograft, automated, including all enzymatic processing and device components (do not report with manual suspension preparation) | California PPO Prior Authorization List, Pg 159 Original policy |
| C8903 | Magnetic resonance imaging with contrast, breast; unilateral | California PPO Prior Authorization List, Pg 160 Original policy |
| C8905 | Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral | California PPO Prior Authorization List, Pg 160 Original policy |
| C8906 | Magnetic resonance imaging with contrast, breast; bilateral | California PPO Prior Authorization List, Pg 160 Original policy |
| C8908 | Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral | California PPO Prior Authorization List, Pg 160 Original policy |
| C9358 | Dermal substitute, native, non-denatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 square centimeters | California PPO Prior Authorization List, Pg 160 Original policy |
| C9363 | Skin substitute, Integra Meshed Bilayer Wound Matrix, per square centimeter | California PPO Prior Authorization List, Pg 160 Original policy |
| C9359 | Porous purified collagen matrix bone void filler (Integra Mozaik Osteoconductive Scaffold Putty, Integra OS Osteoconductive Scaffold Putty), per 0.5 cc | California PPO Prior Authorization List, Pg 160 Original policy |
| C9362 | Porous purified collagen matrix bone void filler (Integra Mozaik Osteoconductive Scaffold Strip), per 0.5 cc | California PPO Prior Authorization List, Pg 160 Original policy |
| C9600 | Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch | California PPO Prior Authorization List, Pg 160 Original policy |
| C9601 | Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery | California PPO Prior Authorization List, Pg 160 Original policy |
| C9602 | Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch | California PPO Prior Authorization List, Pg 160 Original policy |
| C9603 | Percutaneous transluminal coronary atherectomy, with drug- eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery | California PPO Prior Authorization List, Pg 160 Original policy |
| C9604 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel | California PPO Prior Authorization List, Pg 160 Original policy |
| C9605 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 161 Original policy |
| C9607 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty | California PPO Prior Authorization List, Pg 161 Original policy |
| C9608 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft | California PPO Prior Authorization List, Pg 161 Original policy |
| C9764 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed | California PPO Prior Authorization List, Pg 161 Original policy |
| C9765 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed | California PPO Prior Authorization List, Pg 161 Original policy |
| C9766 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed | California PPO Prior Authorization List, Pg 161 Original policy |
| C9767 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed | California PPO Prior Authorization List, Pg 161 Original policy |
| C9772 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed | California PPO Prior Authorization List, Pg 161 Original policy |