Anthem Blue Cross Blue Shield of California prior authorization, page 61
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 |
|---|---|---|
| C9773 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); 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 |
| C9774 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed | California PPO Prior Authorization List, Pg 161 Original policy |
| C9775 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); 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 |
| C9781 | Arthroscopy, shoulder, surgical; with implantation of subacromial spacer (e.g., balloon), includes debridement (e.g., limited or extensive), subacromial decompression, acromioplasty, and biceps tenodesis when performed | California PPO Prior Authorization List, Pg 161 Original policy |
| D9222 | Deep sedation/general anesthesia first 15 minutes | California PPO Prior Authorization List, Pg 161 Original policy |
| D9223 | Deep sedation/general anesthesia - each subsequent 15 minute increment | California PPO Prior Authorization List, Pg 161 Original policy |
| D9950 | Occlusion analysis- mounted case | California PPO Prior Authorization List, Pg 161 Original policy |
| D9951 | Occlusal adjustment- limited | California PPO Prior Authorization List, Pg 161 Original policy |
| D9952 | Occlusal adjustment- complete | California PPO Prior Authorization List, Pg 161 Original policy |
| E0470 | Respiratory assist device, bi-level pressure capability, without back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) | California PPO Prior Authorization List, Pg 161 Original policy |
| E0471 | Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) | California PPO Prior Authorization List, Pg 162 Original policy |
| E0485 | Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment | California PPO Prior Authorization List, Pg 162 Original policy |
| E0486 | Oral device/appliance used to reduce upper airway collapsibility, adjustable or non- adjustable, custom fabricated, includes fitting and adjustment | California PPO Prior Authorization List, Pg 162 Original policy |
| E0491 | Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by hardware remote, 90-day supply | California PPO Prior Authorization List, Pg 162 Original policy |
| E0492 | Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, controlled by phone application | California PPO Prior Authorization List, Pg 162 Original policy |
| E0493 | Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by phone application, 90-day supply | California PPO Prior Authorization List, Pg 162 Original policy |
| E0530 | Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any type | California PPO Prior Authorization List, Pg 162 Original policy |
| E0561 | Humidifier, non-heated, used with positive airway pressure device | California PPO Prior Authorization List, Pg 162 Original policy |
| E0562 | Humidifier, heated, used with positive airway pressure device | California PPO Prior Authorization List, Pg 162 Original policy |
| E0601 | Continuous airway pressure (CPAP) device [may be used for either CPAP or APAP] | California PPO Prior Authorization List, Pg 162 Original policy |
| E0616 | Implantable cardiac event recorder with memory, activator and programmer | California PPO Prior Authorization List, Pg 162 Original policy |
| E0736 | Transcutaneous tibial nerve stimulator [e.g., ZIDA Wearable Neuromodulation control unit, Vivally System with hardware control unit] | California PPO Prior Authorization List, Pg 162 Original policy |
| E0737 | Transcutaneous tibial nerve stimulator, controlled by phone application [e.g., Vivally System, smartphone] | California PPO Prior Authorization List, Pg 162 Original policy |
| E0743 | External lower extremity nerve stimulator for restless legs syndrome, each | California PPO Prior Authorization List, Pg 162 Original policy |
| E0748 | Osteogenesis stimulator, electrical, non-invasive, spinal applications | California PPO Prior Authorization List, Pg 162 Original policy |
| G0260 | Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography | California PPO Prior Authorization List, Pg 162 Original policy |
| G0289 | Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/ shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee | California PPO Prior Authorization List, Pg 162 Original policy |
| G0330 | Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating room | California PPO Prior Authorization List, Pg 162 Original policy |
| G0339 | Robot lin-radsurg com, first | California PPO Prior Authorization List, Pg 162 Original policy |
| G0340 | Robt lin-radsurg fractx 2-5 | California PPO Prior Authorization List, Pg 163 Original policy |
| G0398 | Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation | California PPO Prior Authorization List, Pg 163 Original policy |
| G0399 | Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation | California PPO Prior Authorization List, Pg 163 Original policy |
| G0400 | Home sleep study with type IV portable monitor, unattended; minimum of three channels | California PPO Prior Authorization List, Pg 163 Original policy |
| G0429 | Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy) | California PPO Prior Authorization List, Pg 163 Original policy |
| G0458 | Low dose rate (ldr) prostate brachytherapy services, composite rate | California PPO Prior Authorization List, Pg 163 Original policy |
| G6017 | Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment | California PPO Prior Authorization List, Pg 163 Original policy |
| G9143 | Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s) | California PPO Prior Authorization List, Pg 163 Original policy |
| G9840 | KRAS gene mutation testing performed before initiation of anti- EGFR MoAb | California PPO Prior Authorization List, Pg 163 Original policy |
| G9841 | KRAS gene mutation testing not performed before initiation of anti-EGFR MoAb | California PPO Prior Authorization List, Pg 163 Original policy |
| J0208 | Sodium thiosulfate injection (Pedmark) | California PPO Prior Authorization List, Pg 163 Original policy |
| J0614 | Treosulfan (Grafapex) | California PPO Prior Authorization List, Pg 163 Original policy |
| J0870 | Imetelstat (Rytelo) | California PPO Prior Authorization List, Pg 163 Original policy |
| J1323 | Elranatamab-bcmm (Elrexfio) | California PPO Prior Authorization List, Pg 163 Original policy |
| J1326 | Zolbetuximab-clzb (Vyloy) | California PPO Prior Authorization List, Pg 163 Original policy |
| J1448 | Trilaciclib (Cosela) | California PPO Prior Authorization List, Pg 163 Original policy |
| J1454 | Fosnetupitant Chloride-palonosetron Hcl - (IV ONLY) (Akynzeo) | California PPO Prior Authorization List, Pg 163 Original policy |
| J1460 | Gamma globulin, IM (Gamastan S/D) | California PPO Prior Authorization List, Pg 163 Original policy |
| J1560 | Immune Globulin (Human) (Gamastan) | California PPO Prior Authorization List, Pg 163 Original policy |
| J9282 | Mitomycin intravesical solution (Zusduri) | California PPO Prior Authorization List, Pg 164 Original policy |
| J2562 | Plerixafor Injection (Mozobil) | California PPO Prior Authorization List, Pg 164 Original policy |