Anthem Blue Cross Blue Shield of California prior authorization, page 7
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 |
|---|---|---|
| 90876 | 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); 45 minutes or [when specified as EEG biofeedback or neurofeedback] | California PPO Prior Authorization List, Pg 13 Original policy |
| 90901 | Biofeedback training by any modality or [when specified as EEG biofeedback or neurofeedback] | California PPO Prior Authorization List, Pg 13 Original policy |
| 90912 | Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient | California PPO Prior Authorization List, Pg 13 Original policy |
| 90913 | Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient | California PPO Prior Authorization List, Pg 13 Original policy |
| 93356 | Myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics echocardiography [List separately in addition to codes for echocardiography imaging] | California PPO Prior Authorization List, Pg 13 Original policy |
| 93799 | Unlisted cardiovascular service or procedure [when specified as left ventricular filling pressure; indirect measurement by computerized calibration of the arterial waveform response to Valsalva maneuver] or [when specified as intravascular catheter-based coronary vessel or graft spectroscopy (e.g., infrared) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report, each vessel] or [when specified as insertion of left atrial hemodynamic monitor] | California PPO Prior Authorization List, Pg 14 Original policy |
| 93998 | Unlisted noninvasive vascular diagnostic study [when specified as NIR brain imaging for hematoma screening] | California PPO Prior Authorization List, Pg 14 Original policy |
| 95199 | Unlisted allergy/clinical immunologic service or procedure [when specified as cytotoxic testing for allergies] | California PPO Prior Authorization List, Pg 14 Original policy |
| 95711 | Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; unmonitored | California PPO Prior Authorization List, Pg 14 Original policy |
| 95712 | Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; with intermittent monitoring and maintenance | California PPO Prior Authorization List, Pg 14 Original policy |
| 95713 | Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; with continuous, real-time monitoring and maintenance | California PPO Prior Authorization List, Pg 14 Original policy |
| 95714 | Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; unmonitored | California PPO Prior Authorization List, Pg 14 Original policy |
| 95715 | Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; with intermittent monitoring and maintenance | California PPO Prior Authorization List, Pg 14 Original policy |
| 95716 | Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; with continuous, real-time monitoring and maintenance | California PPO Prior Authorization List, Pg 14 Original policy |
| 95718 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; with video (VEEG) | California PPO Prior Authorization List, Pg 14 Original policy |
| 95720 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpretation and report after each 24-hour period; with video (VEEG) | California PPO Prior Authorization List, Pg 14 Original policy |
| 95722 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 36 hours, up to 60 hours of EEG recording, with video (VEEG) | California PPO Prior Authorization List, Pg 14 Original policy |
| 95724 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 60 hours, up to 84 hours of EEG recording, with video (VEEG) | California PPO Prior Authorization List, Pg 14 Original policy |
| 95726 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 84 hours of EEG recording, with video (VEEG) | California PPO Prior Authorization List, Pg 14 Original policy |
| 95999 | Unlisted neurological or neuromuscular diagnostic procedure [when specified as physiologic recording of tremor using accelerometer(s) and/or gyroscope(s) (including frequency and amplitude), including interpretation and report] or when specified as Sudoscan testing] | California PPO Prior Authorization List, Pg 14 Original policy |
| 96999 | Unlisted special dermatological service or procedure[when specified as dermatoscopy techniques such as dermoscopy, epiluminescence microscopy, or digital epiluminescence microscopy, skin surface microscopy, skin videomicroscopy, incidence light microscopy or reflectance confocal microscopy not generating mosaic images] or [when specified as ultrasonography of the skin for skin lesions] or [when specified as tunable dye or pulsed dye laser treatment for varicose veins] or [when specified as laser treatment of onychomycosis] | California PPO Prior Authorization List, Pg 14 Original policy |
| 97039 | Unlisted modality [when specified as vertebral axial decompression] | California PPO Prior Authorization List, Pg 14 Original policy |
| 97139 | Unlisted therapeutic procedure [when specified as sensory stimulation or coma stimulation therapy] | California PPO Prior Authorization List, Pg 15 Original policy |
| 97151 | Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to- face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan | California PPO Prior Authorization List, Pg 15 Original policy |
| 97152 | Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes | California PPO Prior Authorization List, Pg 15 Original policy |
| 97153 | Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes | California PPO Prior Authorization List, Pg 15 Original policy |
| 97154 | Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes | California PPO Prior Authorization List, Pg 15 Original policy |
| 97155 | Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes | California PPO Prior Authorization List, Pg 15 Original policy |
| 97156 | Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes | California PPO Prior Authorization List, Pg 15 Original policy |
| 97157 | Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes | California PPO Prior Authorization List, Pg 15 Original policy |
| 97158 | Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes | California PPO Prior Authorization List, Pg 15 Original policy |
| 97610 | Low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day | California PPO Prior Authorization List, Pg 15 Original policy |
| 97799 | Unlisted physical medicine/rehabilitation service or procedure [when specified as biomagnetic therapy] or [when specified as sensory stimulation or coma stimulation therapy] or [when specified as isometric or isokinetic testing] | California PPO Prior Authorization List, Pg 15 Original policy |
| 99199 | Unlisted special service, procedure or report [when specified as stress management using wearable devices] or [when specified as an electrical impedance analysis to detect cancer] or [when specified as testing or treatment of idiopathic environmental illness (IEI)] or [when specified as an ingestion event monitor, for example, ID-CAP System or Discover] | California PPO Prior Authorization List, Pg 15 Original policy |
| 0002M | Liver disease, ten biochemical assays (ALT, A2- macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and alcoholic steatohepatitis (ASH) | California PPO Prior Authorization List, Pg 15 Original policy |
| 0003M | Liver disease, ten biochemical assays (ALT, A2- macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and nonalcoholic steatohepatitis (NASH) | California PPO Prior Authorization List, Pg 15 Original policy |
| 0100T | Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy | California PPO Prior Authorization List, Pg 15 Original policy |
| 0202T | Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, including fluoroscopy, single level, lumbar spine | California PPO Prior Authorization List, Pg 15 Original policy |
| 0232T | Injection(s), platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed | California PPO Prior Authorization List, Pg 15 Original policy |
| 0263T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one le.g., including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest | California PPO Prior Authorization List, Pg 15 Original policy |
| 0264T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one le.g., including ultrasound guidance, if performed; complete procedure excluding unilateral or bilateral bone marrow harvest | California PPO Prior Authorization List, Pg 16 Original policy |
| 0265T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one le.g., including ultrasound guidance, if performed; unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy | California PPO Prior Authorization List, Pg 16 Original policy |
| 0345T | Transcatheter mitral valve repair percutaneous approach via the coronary sinus | California PPO Prior Authorization List, Pg 16 Original policy |
| 0362T | Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: - administration by physician or other qualified health care professional who is on site; - with the assistance of two or more technicians; - for a patient who exhibits destructive behavior; - completion in an environment that is customized to the patient's behavior. | California PPO Prior Authorization List, Pg 16 Original policy |
| 0373T | Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: - administration by physician or other qualified health care professional who is on site; - with the assistance of two or more technicians; - for a patient who exhibits destructive behavior; - completion in an environment that is customized to the patient's behavior. | California PPO Prior Authorization List, Pg 16 Original policy |
| 0443T | Real-time spectral analysis of prostate tissue by fluorescence spectroscopy, including imaging guidance | California PPO Prior Authorization List, Pg 16 Original policy |
| 0472T | Device evaluation, interrogation, and initial programming of intra-ocular retinal electrode array (e.g., retinal prosthesis), in person, with iterative adjustment of the implantable device to test functionality, select optimal permanent programmed values with analysis, including visual training, with review and report by a qualified health care professional | California PPO Prior Authorization List, Pg 16 Original policy |
| 0440T | Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve | California PPO Prior Authorization List, Pg 16 Original policy |
| 0441T | Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve | California PPO Prior Authorization List, Pg 16 Original policy |
| 0442T | Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (e.g., brachial plexus, pudendal nerve) | California PPO Prior Authorization List, Pg 16 Original policy |