Anthem Blue Cross Blue Shield of California prior authorization, page 9
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 |
|---|---|---|
| 1059T | Removal of implanted subcutaneous unilateral supraorbital and occipital neurostimulator system | California PPO Prior Authorization List, Pg 18 Original policy |
| 1060T | Electronic analysis of implanted subcutaneous supraorbital- occipital neurostimulator pulse generator (eg, frequency, amplitude, pulse width, leads, electrode configuration); with complex programming by physician or other qualified health care professional | California PPO Prior Authorization List, Pg 18 Original policy |
| 1061T | Electronic analysis of implanted subcutaneous supraorbital- occipital neurostimulator pulse generator (eg, frequency, amplitude, pulse width, leads, electrode configuration); with simple programming by physician or other qualified health care professional | California PPO Prior Authorization List, Pg 19 Original policy |
| 1072T | Liver allograft, normothermic machine perfusion; each additional hour of monitoring and management | California PPO Prior Authorization List, Pg 19 Original policy |
| 1073T | Liver allograft, normothermic machine perfusion; decannulation | California PPO Prior Authorization List, Pg 19 Original policy |
| 1083T | Stereotactic placement of infusion catheter(s), brain, for delivery of therapeutic agent(s), including computerized stereotactic planning and burr hole(s) | California PPO Prior Authorization List, Pg 19 Original policy |
| 1092T | Implantation of acellular scaffold (eg, hyaluronan), knee, single implant; into chondral defect, open | California PPO Prior Authorization List, Pg 19 Original policy |
| 1093T | Implantation of acellular scaffold (eg, hyaluronan), knee, single implant; into a chondral or osteochondral defect, arthroscopic | California PPO Prior Authorization List, Pg 19 Original policy |
| 1094T | Implantation of acellular scaffold (eg, hyaluronan), knee, single implant; each additional acellular scaffold implantation | California PPO Prior Authorization List, Pg 19 Original policy |
| 1095T | Harvesting and processing of autologous bone marrow aspirate concentrate (BMAC), with application onto scaffold or injection into anatomical recipient site (eg, subchondral bone, joint space, chondral lesion), including imaging guidance, when performed, for therapeutic musculoskeletal treatment, excluding spinal procedures | California PPO Prior Authorization List, Pg 19 Original policy |
| 1160T | Oncology (breast), augmentative algorithmic analysis of histomorphologic features in digitized hematoxylin and eosin stained slides from formalin-fixed paraffin-embedded (FFPE) breast cancer tissue, algorithm-derived parameters reported as 5-year and 10-year risks of distant metastasis, including digitization of glass microscope slides and hematoxylin and eosin staining of tissue sections, when performed [ArteraAI Breast Cancer test] | California PPO Prior Authorization List, Pg 19 Original policy |
| 1107T | Oncology (prostate), augmentative algorithmic analysis of histomorphologic features in digitized hematoxylin and eosin stained slide(s) from formalin-fixed paraffin-embedded (FFPE) prostate cancer tissue, algorithm-derived parameters reported as 10-year risk of distant metastasis and prostate cancer specific mortality, including hematoxylin and eosin staining of tissue sections, and digitization of glass microscope slides, when performed [ArteraAI Prostate test algorithm] | California PPO Prior Authorization List, Pg 19 Original policy |
| 0080U | Oncology (lung), mass spectrometric analysis of galectin-3- binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk factors (age, smoking status, nodule diameter, nodule-spiculation status and nodule location), utilizing plasma, algorithm reported as a categorical probability of malignancy | California PPO Prior Authorization List, Pg 19 Original policy |
| 0088U | Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizing transplant biopsy tissue, algorithm reported as a probability score for rejection. | California PPO Prior Authorization List, Pg 19 Original policy |
| 0105U | Nephrology (chronic kidney disease), multiplex electrochemiluminescent immunoassay (ECLIA) of tumor necrosis factor receptor 1A, receptor superfamily 2 (TNFR1, TNFR2), and kidney injury molecule-1 (KIM-1) combined with longitudinal clinical data, including APOL1 genotype if available, and plasma (isolated fresh or frozen), algorithm reported as probability score for rapid kidney function decline (RKFD) | California PPO Prior Authorization List, Pg 19 Original policy |
| 0108U | Gastroenterology (Barrett’s esophagus), whole slide-digital imaging, including morphometric analysis, computer-assisted quantitative immunolabeling of 9 protein biomarkers (p16, AMACR, p53, CD68, COX-2, CD45RO, HIF1a, HER-2, K20) and morphology, formalin-fixed paraffin-embedded tissue, algorithm reported as risk of progression to high-grade dysplasia or cancer | California PPO Prior Authorization List, Pg 19 Original policy |
| 0117U | Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid (3-HPMA), quinolinic acid, kynurenic acid), LC-MS/MS, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain | California PPO Prior Authorization List, Pg 19 Original policy |
| 0133U | Hereditary prostate cancer-related disorders, targeted mRNA sequence analysis panel (11 genes) | California PPO Prior Authorization List, Pg 19 Original policy |
| 0157U | APC (APC regulator of WNT signaling pathway) (e.g., familial adenomatosis polyposis [FAP]) mRNA sequence analysis | California PPO Prior Authorization List, Pg 20 Original policy |
| 0158U | MLH1 (mutL homolog 1) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis | California PPO Prior Authorization List, Pg 20 Original policy |
| 0159U | MSH2 (mutS homolog 2) (e.g., hereditary colon cancer, Lynch syndrome) mRNA sequence analysis | California PPO Prior Authorization List, Pg 20 Original policy |
| 0160U | MSH6 (mutS homolog 6) (e.g., hereditary colon cancer, Lynch syndrome) mRNA sequence analysis | California PPO Prior Authorization List, Pg 20 Original policy |
| 0161U | PMS2 (PMS1 homolog 2, mismatch repair system component) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis | California PPO Prior Authorization List, Pg 20 Original policy |
| 0162U | Hereditary colon cancer (Lynch syndrome), targeted mRNA sequence analysis panel (MLH1, MSH2, MSH6, PMS2) | California PPO Prior Authorization List, Pg 20 Original policy |
| 0164U | Gastroenterology (irritable bowel syndrome [IBS]), immunoassay for antiCdtB and anti-vinculin antibodies, utilizing plasma, algorithm for elevated or not elevated qualitative results | California PPO Prior Authorization List, Pg 20 Original policy |
| 0166U | Liver disease, 10 biochemical assays (α2-macroglobulin, haptoglobin, apolipoprotein A1, bilirubin, GGT, ALT, AST, triglycerides, cholesterol, fasting glucose) and biometric and demographic data, utilizing serum, algorithm reported as scores for fibrosis, necroinflammatory activity, and steatosis with a summary interpretation | California PPO Prior Authorization List, Pg 20 Original policy |
| 0207U | Neurology (Alzheimer disease); quantitative imaging of phosphorylated ERK1 and ERK2 in response to bradykinin treatment by in situ immunofluorescence, using cultured skin fibroblasts, reported as a probability index for Alzheimer disease | California PPO Prior Authorization List, Pg 20 Original policy |
| 0247U | Obstetrics (preterm birth), insulin-like growth factor-binding protein 4 (IBP4), sex hormone-binding globulin (SHBG), quantitative measurement by LC-MS/MS, utilizing maternal blood and blood derivatives, combined with clinical data, reported as predictive-risk stratification for spontaneous preterm birth | California PPO Prior Authorization List, Pg 20 Original policy |
| 0248U | Oncology (brain), spheroid cell culture in a 3D microenvironment, 12 drug panel, tumor-response prediction for each drug | California PPO Prior Authorization List, Pg 20 Original policy |
| 0312U | Autoimmune diseases (e.g., systemic lupus erythematosus [SLE]), analysis of 8 IgG autoantibodies and 2 cell-bound complement activation products using enzyme-linked immunosorbent immunoassay (ELISA), flow cytometry and indirect immunofluorescence, serum, or plasma and whole blood, individual components reported along with an algorithmic SLE-likelihood assessment | California PPO Prior Authorization List, Pg 20 Original policy |
| 0344U | Hepatology (nonalcoholic fatty liver disease [NAFLD]), semiquantitative evaluation of 28 lipid markers by liquid chromatography with tandem mass spectrometry (LC- MS/MS), serum, reported as at-risk for nonalcoholic steatohepatitis (NASH) or not NASH | California PPO Prior Authorization List, Pg 20 Original policy |
| 0358U | Neurology (mild cognitive impairment), analysis of β-amyloid 1- 42 and 1-40, chemiluminescence enzyme immunoassay, cerebral spinal fluid, reported as positive, likely positive, or negative | California PPO Prior Authorization List, Pg 20 Original policy |
| 0360U | Oncology (lung), enzyme-linked immunosorbent assay (ELISA) of 7 autoantibodies (p53, NY-ESO-1, CAGE, GBU4- 5, SOX2, MAGE A4, and HuD), plasma, algorithm reported as a categorical result for risk of malignancy | California PPO Prior Authorization List, Pg 20 Original policy |
| 0376U | Oncology (prostate cancer), image analysis of at least 128 histologic features and clinical factors, prognostic algorithm determining the risk of distant metastases, and prostate cancer-specific mortality, includes predictive algorithm to androgen deprivation-therapy response, if appropriate | California PPO Prior Authorization List, Pg 20 Original policy |
| 0407U | Nephrology (diabetic chronic kidney disease [CKD]), multiplex electrochemiluminescent immunoassay (ECLIA) of soluble tumor necrosis factor receptor 1 (sTNFR1), soluble tumor necrosis receptor 2 (sTNFR2), and kidney injury molecule 1 (KIM-1) combined with clinical data, plasma, algorithm reported as risk for progressive decline in kidney function | California PPO Prior Authorization List, Pg 20 Original policy |
| 0412U | Beta amyloid, Aβ42/40 ratio, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and qualitative ApoE isoformspecific proteotyping, plasma combined with age, algorithm reported as presence or absence of brain amyloid pathology | California PPO Prior Authorization List, Pg 21 Original policy |
| 0435U | Oncology, chemotherapeutic drug cytotoxicity assay of cancer stem cells (CSCs), from cultured CSCs and primary tumor cells, categorical drug response reported based on cytotoxicity percentage observed, minimum of 14 drugs or drug combinations | California PPO Prior Authorization List, Pg 21 Original policy |
| 0457U | Perfluoroalkyl substances (PFAS) (e.g., perfluorooctanoic acid, perfluorooctane sulfonic acid), 9 PFAS compounds by LC-MS/MS, plasma or serum, quantitative | California PPO Prior Authorization List, Pg 21 Original policy |
| 0459U | β-amyloid (Abeta42) and total tau (tTau), electrochemiluminescent immunoassay (ECLIA), cerebral spinal fluid, ratio reported as positive or negative for amyloid pathology (Elecsys® Total Tau CSF [tTau] and β-Amyloid [1- 42] CSF II [Abeta 42] Ratio) | California PPO Prior Authorization List, Pg 21 Original policy |
| 0480U | Infectious disease (bacteria, viruses, fungi, and parasites), cerebrospinal fluid (CSF), metagenomic next-generation sequencing (DNA and RNA), bioinformatic analysis, with positive pathogen identification | California PPO Prior Authorization List, Pg 21 Original policy |
| 0482U | Obstetrics (preeclampsia), biochemical assay of soluble fms- like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF), serum, ratio reported for sFlt1/PlGF, with risk of progression for preeclampsia with severe features within 2 weeks | California PPO Prior Authorization List, Pg 21 Original policy |
| 0503U | Neurology (Alzheimer disease), beta amyloid (AB40, AB42, AB42/40 ratio) and tau-protein (ptau217, np-tau217, ptau217/np-tau217 ratio), blood, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (LC-MS/MS), algorithm score reported as likelihood of positive or negative for amyloid plaques | California PPO Prior Authorization List, Pg 21 Original policy |
| 0521U | Rheumatoid factor IgA and IgM, cyclic citrullinated peptide (CCP) antibodies, and scavenger receptor A (SR-A) by immunoassay, blood | California PPO Prior Authorization List, Pg 21 Original policy |
| 0524U | Obstetrics (preeclampsia), sFlt1/PlGF ratio, immunoassay, utilizing serum or plasma, reported as a value | California PPO Prior Authorization List, Pg 21 Original policy |
| 0548U | Glial fibrillary acidic protein (GFAP), chemiluminescent enzyme immunoassay, using plasma | California PPO Prior Authorization List, Pg 21 Original policy |
| 0596U | Neurology (Alzheimer disease), plasma, 3 distinct isoform- specific peptides (APOE2, APOE3, and APOE4) by liquid chromatography with tandem mass spectrometry (LC- MS/MS), reported as an APOE proteotype | California PPO Prior Authorization List, Pg 21 Original policy |
| 0598U | Gastroenterology (irritable bowel syndrome), IgG antibodies to 18 food items by enzyme-linked immunosorbent assay (ELISA), whole blood or serum, report as elevated (positive) or normal (negative) antibody levels | California PPO Prior Authorization List, Pg 21 Original policy |
| 0600U | Infectious disease (wound infection), identification of 65 organisms and 30 antibiotic resistance genes, wound swab, real-time PCR, reported as positive or negative for each organism | California PPO Prior Authorization List, Pg 21 Original policy |
| 0665U | Hepatology (metabolic dysfunction-associated steatohepatitis [MASH]), enzyme-linked immunosorbent assay (ELISA) for YKL40 and quantitative reverse transcription polymerase chain reaction (RT-qPCR) for miR-34a-5p, serum, algorithm reported as a single score for MASH activity and fibrosis | California PPO Prior Authorization List, Pg 21 Original policy |
| A0430 | Ambulance service, conventional air services, transport, one way (fixed wing) | California PPO Prior Authorization List, Pg 21 Original policy |