Anthem Blue Cross Blue Shield of California prior authorization, page 8
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 |
|---|---|---|
| 0473T | Device evaluation and interrogation of intra-ocular retinal electrode array (e.g., retinal prosthesis), in person, including reprogramming and visual training, when performed, with review and report by a qualified health care professional | California PPO Prior Authorization List, Pg 16 Original policy |
| 0481T | Injection(s), autologous white blood cell concentrate (autologous protein solution), any site, including image guidance, harvesting and preparation, when performed | California PPO Prior Authorization List, Pg 16 Original policy |
| 0483T | Transcatheter mitral valve implantation/ replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed | California PPO Prior Authorization List, Pg 16 Original policy |
| 0484T | Transcatheter mitral valve implantation/ replacement (TMVI) with prosthetic valve; transthoracic exposure (e.g., thoracotomy, transapical) | California PPO Prior Authorization List, Pg 16 Original policy |
| 0494T | Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system, including decannulation, separation from the perfusion system, and cold preservation of the allograft prior to implantation, when performed | California PPO Prior Authorization List, Pg 16 Original policy |
| 0495T | Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (e.g., pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; first two hours in sterile field | California PPO Prior Authorization List, Pg 16 Original policy |
| 0496T | Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (e.g., pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; each additional hour | California PPO Prior Authorization List, Pg 16 Original policy |
| 0513T | Extracorporeal shock wave for integumentary wound healing, including topical application and dressing care; each additional wound | California PPO Prior Authorization List, Pg 17 Original policy |
| 0544T | Transcatheter mitral valve annulus reconstruction, with implantation of adjustable annulus reconstruction device, percutaneous approach including transseptal puncture | California PPO Prior Authorization List, Pg 17 Original policy |
| 0545T | Transcatheter tricuspid valve annulus reconstruction with implantation of adjustable annulus reconstruction device, percutaneous approach | California PPO Prior Authorization List, Pg 17 Original policy |
| 0569T | Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis | California PPO Prior Authorization List, Pg 17 Original policy |
| 0570T | Transcatheter tricuspid valve repair, percutaneous approach; each additional prosthesis during same session | California PPO Prior Authorization List, Pg 17 Original policy |
| 0584T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; percutaneous | California PPO Prior Authorization List, Pg 17 Original policy |
| 0585T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; laparoscopic | California PPO Prior Authorization List, Pg 17 Original policy |
| 0586T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; open | California PPO Prior Authorization List, Pg 17 Original policy |
| 0646T | Transcatheter tricuspid valve implantation (TTVI)/replacement with prosthetic valve, percutaneous approach, including right heart catheterization, temporary pacemaker insertion, and selective right ventricular or right atrial angiography, when performed | California PPO Prior Authorization List, Pg 17 Original policy |
| 0659T | Transcatheter intracoronary infusion of supersaturated oxygen in conjunction with percutaneous coronary revascularization during acute myocardial infarction, including catheter placement, imaging guidance (e.g., fluoroscopy), angiography, and radiologic supervision and interpretation | California PPO Prior Authorization List, Pg 17 Original policy |
| 0664T | Donor hysterectomy (including cold preservation); open, from cadaver donor | California PPO Prior Authorization List, Pg 17 Original policy |
| 0665T | Donor hysterectomy (including cold preservation); open, from living donor | California PPO Prior Authorization List, Pg 17 Original policy |
| 0666T | Donor hysterectomy (including cold preservation); laparoscopic or robotic, from living donor | California PPO Prior Authorization List, Pg 17 Original policy |
| 0667T | Recipient uterus allograft transplantation from cadaver or living donor | California PPO Prior Authorization List, Pg 17 Original policy |
| 0668T | Backbench standard preparation of cadaver or living donor uterine allograft prior to transplantation, including dissection and removal of surrounding soft tissues and preparation of uterine vein(s) and uterine artery(ies), as necessary | California PPO Prior Authorization List, Pg 17 Original policy |
| 0669T | Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; venous anastomosis, each | California PPO Prior Authorization List, Pg 17 Original policy |
| 0670T | Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; arterial anastomosis, each | California PPO Prior Authorization List, Pg 17 Original policy |
| 0686T | Histotripsy (i.e., non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance | California PPO Prior Authorization List, Pg 17 Original policy |
| 0690T | Quantitative ultrasound tissue characterization (nonelastographic), including interpretation and report, obtained without diagnostic ultrasound examination of the same anatomy (eg, organ, gland, tissue, target structure) | California PPO Prior Authorization List, Pg 17 Original policy |
| 0692T | Therapeutic ultrafiltration | California PPO Prior Authorization List, Pg 17 Original policy |
| 0738T | Treatment planning for magnetic field induction ablation of malignant prostate tissue, using data from previously performed magnetic resonance imaging (MRI) examination | California PPO Prior Authorization List, Pg 17 Original policy |
| 0739T | Ablation of malignant prostate tissue by magnetic field induction, including all intraprocedural, transperineal needle/catheter placement for nanoparticle installation and intraprocedural temperature monitoring, thermal dosimetry, bladder irrigation, and magnetic field nanoparticle activation | California PPO Prior Authorization List, Pg 17 Original policy |
| 0748T | Injections of stem cell product into perianal perifistular soft tissue, including fistula preparation (e.g., removal of setons, fistula curettage, closure of internal openings) | California PPO Prior Authorization List, Pg 17 Original policy |
| 0810T | Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies | California PPO Prior Authorization List, Pg 17 Original policy |
| 0813T | Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of intragastric bariatric balloon | California PPO Prior Authorization List, Pg 17 Original policy |
| 0888T | Histotripsy (i.e., non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including imaging guidance | California PPO Prior Authorization List, Pg 18 Original policy |
| 0894T | Cannulation of the liver allograft in preparation for connection to the normothermic perfusion device and decannulation of the liver allograft following normothermic perfusion | California PPO Prior Authorization List, Pg 18 Original policy |
| 0895T | Connection of liver allograft to normothermic machine perfusion device, hemostasis control; initial 4 hours of monitoring time, including hourly physiological and laboratory assessments (e.g., perfusate temperature, perfusate pH, hemodynamic parameters, bile production, bile pH, bile glucose, biliary bicarbonate, lactate levels, macroscopic assessment) | California PPO Prior Authorization List, Pg 18 Original policy |
| 0896T | Connection of liver allograft to normothermic machine perfusion device, hemostasis control; each additional hour, including physiological and laboratory assessments (e.g., perfusate temperature, perfusate pH, hemodynamic parameters, bile production, bile pH, bile glucose, biliary bicarbonate, lactate levels, macroscopic assessment) | California PPO Prior Authorization List, Pg 18 Original policy |
| 0915T | Insertion of permanent cardiac contractility modulation- defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse generator and dual transvenous electrodes/leads (pacing and defibrillation) | California PPO Prior Authorization List, Pg 18 Original policy |
| 0923T | Removal and replacement of permanent cardiac contractility modulation-defibrillation pulse generator only | California PPO Prior Authorization List, Pg 18 Original policy |
| 0933T | Transcatheter implantation of wireless left atrial pressure sensor for long-term left atrial pressure monitoring, including sensor calibration and deployment, right heart catheterization, transseptal puncture, imaging guidance, and radiological supervision and interpretation | California PPO Prior Authorization List, Pg 18 Original policy |
| 1088T | Percutaneous application of high-frequency neuromodulation signals using microneedle electrode array for the treatment of nociceptive or neuropathic pain, including electrode placement and patient training, per day | California PPO Prior Authorization List, Pg 18 Original policy |
| 1020T | Raman spectroscopy of 1 or more skin lesions, with probability score for malignant risk derived by algorithmic analysis of data from each lesion | California PPO Prior Authorization List, Pg 18 Original policy |
| 1037T | Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant pancreatic tissue, including imaging guidance | California PPO Prior Authorization List, Pg 18 Original policy |
| 1044T | Harvest of full-thickness skin for autologous heterogeneous skin-construct graft, including direct closure of donor site; first 5 sq cm or less | California PPO Prior Authorization List, Pg 18 Original policy |
| 1045T | Harvest of full-thickness skin for autologous heterogeneous skin-construct graft, including direct closure of donor site; each additional 5 sq cm, or part thereof | California PPO Prior Authorization List, Pg 18 Original policy |
| 1046T | Autologous heterogeneous skin-construct graft application, trunk, arms, legs; first 50 sq cm or less, or 0.5% of body area of infants and children | California PPO Prior Authorization List, Pg 18 Original policy |
| 1047T | Autologous heterogeneous skin-construct graft application, trunk, arms, legs; each additional 50 sq cm, or each additional 0.5% of body area of infants and children, or part thereof | California PPO Prior Authorization List, Pg 18 Original policy |
| 1048T | Autologous heterogeneous skin-construct graft application, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 50 sq cm or less, or 0.5% of body area of infants and children | California PPO Prior Authorization List, Pg 18 Original policy |
| 1049T | Autologous heterogeneous skin-construct graft application, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 50 sq cm, or each additional 0.5% of body area of infants and children, or part thereof | California PPO Prior Authorization List, Pg 18 Original policy |
| 1057T | Insertion or replacement of subcutaneous neurostimulator pulse generators, with tunneling of 4 electrode arrays, bilateral supraorbital and occipital nerves, including all interrogation, programming, and imaging guidance, when performed | California PPO Prior Authorization List, Pg 18 Original policy |
| 1058T | Revision of implanted subcutaneous unilateral supraorbital and occipital neurostimulator system, including all interrogation, programming, and imaging guidance, when performed | California PPO Prior Authorization List, Pg 18 Original policy |