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Anthem Blue Cross Blue Shield of California prior authorization, page 64

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

Prior authorization codes
CodeDescriptionSource
J9601Linvoseltamab-gcpt (Lynozyfic)California PPO Prior Authorization List, Pg 169 Original policy
K1027Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustmentCalifornia PPO Prior Authorization List, Pg 169 Original policy
L8607Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary suppliesCalifornia PPO Prior Authorization List, Pg 169 Original policy
L8690Auditory osseointegrated device, includes all internal and external componentsCalifornia PPO Prior Authorization List, Pg 169 Original policy
L8691Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, eachCalifornia PPO Prior Authorization List, Pg 169 Original policy
L8692Auditory osseointegrated device, external sound processor; used without osseointegration, body worn, includes headband or other means of external attachmentCalifornia PPO Prior Authorization List, Pg 169 Original policy
L8693Auditory osseointegrated device, abutment, any length, replacement onlyCalifornia PPO Prior Authorization List, Pg 169 Original policy
L8694Auditory osseointegrated device, transducer/actuator, replacement only, eachCalifornia PPO Prior Authorization List, Pg 170 Original policy
Q2026Injection, Radiesse, 0.1 mlCalifornia PPO Prior Authorization List, Pg 170 Original policy
Q2028Injection, Sculptra, 0.5 mgCalifornia PPO Prior Authorization List, Pg 170 Original policy
Q2043Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion (Provenge)California PPO Prior Authorization List, Pg 170 Original policy
Q2053Sacituzumab govitecan-hziy, 10 mg (Tecartus)California PPO Prior Authorization List, Pg 170 Original policy
Q2056Ciltacabtagene autoleucel (Carvykti)California PPO Prior Authorization List, Pg 170 Original policy
Q3001Brachytherapy RadioelementsCalifornia PPO Prior Authorization List, Pg 170 Original policy
Q4101Apligraf, per square centimeterCalifornia PPO Prior Authorization List, Pg 170 Original policy
Q4102Oasis Wound Matrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 170 Original policy
Q4104Integra Bilayer Matrix Wound Dressing (BMWD), per square centimeterCalifornia PPO Prior Authorization List, Pg 170 Original policy
Q4105Integra Dermal Regeneration Template (DRT) or Integra Omnigraft dermal regeneration matrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 170 Original policy
Q4107GraftJacket, per square centimeterCalifornia PPO Prior Authorization List, Pg 170 Original policy
Q4110PriMatrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 170 Original policy
Q4115AlloSkin, per square centimeterCalifornia PPO Prior Authorization List, Pg 170 Original policy
Q4116AlloDerm, per square centimeter [AlloDerm RTM, AlloDerm RTU for breast reconstruction and abdominal wall wounds]California PPO Prior Authorization List, Pg 170 Original policy
Q4121TheraSkin, per square centimeterCalifornia PPO Prior Authorization List, Pg 170 Original policy
Q4122Dermacell, Dermacell AWM or Dermacell AWM porous, per square centimeter [for breast reconstruction or diabetic foot ulcers only]California PPO Prior Authorization List, Pg 170 Original policy
Q4124Oasis Ultra Tri-Layer Wound Matrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 170 Original policy
Q4128FlexHD, or Allopatch HD, per sq cm [when specified as FlexHD for breast reconstruction]California PPO Prior Authorization List, Pg 170 Original policy
Q4130Strattice, per square centimeter [for breast reconstruction and abdominal wall wounds]California PPO Prior Authorization List, Pg 171 Original policy
Q4133Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per square centimeter [when specified as Grafix PRIME, for diabetic foot ulcers only] or [when specified as GrafixPL PRIME, Stravix, StravixPL]California PPO Prior Authorization List, Pg 171 Original policy
Q4151AmnioBand or Guardian, per sq cm [for diabetic foot ulcers only]]California PPO Prior Authorization List, Pg 171 Original policy
Q4154Biovance, per square centimeterCalifornia PPO Prior Authorization List, Pg 171 Original policy
Q4158Kerecis Omega3, per square centimeterCalifornia PPO Prior Authorization List, Pg 171 Original policy
Q4160NuShield, per square centimeterCalifornia PPO Prior Authorization List, Pg 171 Original policy
Q4186EpiFix, per square centimeterCalifornia PPO Prior Authorization List, Pg 171 Original policy
Q4187EpiCord, per square centimeter [for diabetic foot ulcers only]California PPO Prior Authorization List, Pg 171 Original policy
Q4283Biovance Tri-layer or Biovance 3L, per square centimeterCalifornia PPO Prior Authorization List, Pg 171 Original policy
Q4334AmnioPlast 1, per square centimeterCalifornia PPO Prior Authorization List, Pg 171 Original policy
Q4335AmnioPlast 2, per square centimeterCalifornia PPO Prior Authorization List, Pg 171 Original policy
Q4369AmnioPlast 3, per square centimeterCalifornia PPO Prior Authorization List, Pg 171 Original policy
Q5107Mvasi (bevacizumab-awwb)California PPO Prior Authorization List, Pg 171 Original policy
Q5112Ontruzant (trastuzumab-dttb)California PPO Prior Authorization List, Pg 171 Original policy
Q5113Herzuma (trastuzumab-pkrb)California PPO Prior Authorization List, Pg 171 Original policy
Q5114Ogivri (trastuzumab-dkst)California PPO Prior Authorization List, Pg 171 Original policy
Q5116Trazimera (trastuzumab-qyyp)California PPO Prior Authorization List, Pg 171 Original policy
Q5118Zirabev (bevacizumab-bvzr)California PPO Prior Authorization List, Pg 171 Original policy
Q5146Trastuzumab-strf (Hercessi)California PPO Prior Authorization List, Pg 171 Original policy
Q5160Bevacizumab-nwgd (Jobevne)California PPO Prior Authorization List, Pg 172 Original policy
Q5165Denosumab-mobz (Oziltus)California PPO Prior Authorization List, Pg 172 Original policy
Q9982Flutemetamol f18, diagnostic, per study dose, up to 5 millicuriesCalifornia PPO Prior Authorization List, Pg 172 Original policy
Q9983Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuriesCalifornia PPO Prior Authorization List, Pg 172 Original policy
S2112Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)California PPO Prior Authorization List, Pg 172 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.

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