Anthem Blue Cross Blue Shield of California prior authorization, page 65
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 |
|---|---|---|
| S2118 | Metal-on-metal total hip resurfacing, including acetabular and femoral components | California PPO Prior Authorization List, Pg 172 Original policy |
| S2202 | Echosclerotherapy | California PPO Prior Authorization List, Pg 172 Original policy |
| S2342 | Nasal endoscopy for post-operative debridement following functional endoscopic sinus surgery, nasal and/or sinus cavity(s), unilateral or bilateral | California PPO Prior Authorization List, Pg 172 Original policy |
| S3800 | Genetic testing for amyotrophic lateral sclerosis (ALS) | California PPO Prior Authorization List, Pg 172 Original policy |
| S3840 | DNA analysis for germline mutations of the RET proto- oncogene for susceptibility to multiple endocrine neoplasia type 2 | California PPO Prior Authorization List, Pg 172 Original policy |
| S3841 | Genetic testing for retinoblastoma | California PPO Prior Authorization List, Pg 172 Original policy |
| S3842 | Genetic testing for von Hippel-Lindau disease | California PPO Prior Authorization List, Pg 172 Original policy |
| S3844 | DNA analysis of the connexin 26 gene (gjb2) for susceptibility to congenital, profound deafness | California PPO Prior Authorization List, Pg 172 Original policy |
| S3845 | Genetic testing for alpha-thalassemia | California PPO Prior Authorization List, Pg 172 Original policy |
| S3846 | Genetic testing for hemoglobin E beta-thalassemia | California PPO Prior Authorization List, Pg 172 Original policy |
| S3849 | Genetic testing for Niemann-Pick diseases | California PPO Prior Authorization List, Pg 172 Original policy |
| S3850 | Genetic testing for sickle cell anemia | California PPO Prior Authorization List, Pg 172 Original policy |
| S3852 | DNA analysis for APOE epsilon 4 allele for susceptibility to Alzheimer's disease | California PPO Prior Authorization List, Pg 172 Original policy |
| S3853 | Genetic testing for myotonic muscular dystrophy | California PPO Prior Authorization List, Pg 173 Original policy |
| S3854 | Gene expression profiling panel for use in the management of breast cancer treatment | California PPO Prior Authorization List, Pg 173 Original policy |
| S3861 | Genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and variants for suspected Brugada syndrome | California PPO Prior Authorization List, Pg 173 Original policy |
| S3865 | Comprehensive gene sequence analysis for hypertrophic cardiomyopathy | California PPO Prior Authorization List, Pg 173 Original policy |
| S3866 | Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family | California PPO Prior Authorization List, Pg 173 Original policy |
| S3870 | Comparative genomic hybridization (CGH) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability | California PPO Prior Authorization List, Pg 173 Original policy |
| S8030 | Scleral application of tantalum ring(s) for localization of lesions for proton beam therapy | California PPO Prior Authorization List, Pg 173 Original policy |
| V2790 | Amniotic membrane for surgical reconstruction, per procedure | California PPO Prior Authorization List, Pg 173 Original policy |
| V5298 | Hearing aid, not otherwise classified [when specified as an intraoral bone conduction hearing aid] | California PPO Prior Authorization List, Pg 173 Original policy |
| 90283 | Immune globulin, IVIG Generic | California PPO Prior Authorization List, Pg 174 Original policy |
| 90284 | Immune globulin subcutaneous [Human], SCIg | California PPO Prior Authorization List, Pg 174 Original policy |
| 90382 | Clesrovimab-cfor (Enflonsia) | California PPO Prior Authorization List, Pg 174 Original policy |
| 90378 | Palivizumab (Synagis) | California PPO Prior Authorization List, Pg 174 Original policy |
| 90380 | Nirsevimab (Beyfortus) | California PPO Prior Authorization List, Pg 174 Original policy |
| 90381 | Nirsevimab (Beyfortus) | California PPO Prior Authorization List, Pg 174 Original policy |
| C9047 | Caplacizumab-ydhp (Cablivi) | California PPO Prior Authorization List, Pg 174 Original policy |
| C9257 | Bevacizumab, 0.25 mg intravitreal (Avastin) | California PPO Prior Authorization List, Pg 174 Original policy |
| C9311 | Eplontersen (Wainua) | California PPO Prior Authorization List, Pg 174 Original policy |
| G2082 | Esketamine (Spravato) | California PPO Prior Authorization List, Pg 176 Original policy |
| G2083 | Esketamine (Spravato) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0013 | Esketamine (Spravato) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0129 | Abatacept (Orencia) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0139 | Adalimumab (Humira) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0174 | Lecanemab-irmb (Leqembi) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0175 | Donanemab-azbt (Kisunla) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0177 | Aflibercept (Eylea HD) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0178 | Aflibercept (Eylea) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0179 | Brolucizumab-dbll (Beovu) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0180 | Agalsidase Beta (Fabrazyme) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0202 | Alemtuzumab (Lemtrada) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0217 | Velmanase alfa-tycv (Lamzede) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0218 | Olipudase alfa (Xenpozyme) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0219 | Avalglucosidase alfa-ngpt (Nexviazyme) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0221 | Alglucosidase alfa (Lumizyme) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0222 | Patisiran (Onpattro) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0223 | Givosiran (Givlaari) | California PPO Prior Authorization List, Pg 176 Original policy |
| J0224 | Lumasiran (Oxlumo) | California PPO Prior Authorization List, Pg 176 Original policy |