Anthem Blue Cross Blue Shield of California policy
Anthem Blue Cross Facility Provider Manual
Anthem Blue Cross Facility Provider Manual is a public Anthem Blue Cross Blue Shield of California policy (effective Mar 1, 2017). It lists 121 CPT or HCPCS codes, 21 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
View the original policy (PDF) ↗
- Effective
- Mar 1, 2017
- Line of business
- Commercial, Medicaid
- States
- CA
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California policies |
|---|---|---|---|
| 00004 | Not listed | Policies naming 00004 | |
| 00005 | Not listed | Policies naming 00005 | |
| 06492 | Not listed | Policies naming 06492 | |
| 10133 | Not listed | Policies naming 10133 | |
| 10169 | Not listed | Policies naming 10169 | |
| 10940 | Not listed | Policies naming 10940 | |
| 12211 | Not listed | Policies naming 12211 | |
| 13550 | Not listed | Policies naming 13550 | |
| 21555 | Not listed | Policies naming 21555 | |
| 22222 | On the list | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic | Policies naming 22222 |
| 23230 | Not listed | Policies naming 23230 | |
| 24011 | Not listed | Policies naming 24011 | |
| 30326 | Not listed | Policies naming 30326 | |
| 30348 | Not listed | Policies naming 30348 | |
| 31193 | Not listed | Policies naming 31193 | |
| 31820 | Not listed | Policies naming 31820 | |
| 32851 | On the list | Lung transplant, single; without cardiopulmonary bypass | Policies naming 32851 |
| 33945 | On the list | Heart transplant, with or without recipient cardiectomy | Policies naming 33945 |
| 36415 | Not listed | Policies naming 36415 | |
| 36416 | Not listed | Policies naming 36416 | |
| 36430 | Not listed | Policies naming 36430 | |
| 36511 | On the list | Therapeutic apheresis; for white blood cells | Policies naming 36511 |
| 36516 | On the list | Therapeutic apheresis; with extracorporeal immunoadsorption, selective adsorption or selective filtration and plasma reinfusion | Policies naming 36516 |
| 38205 | On the list | Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic | Policies naming 38205 |
| 38206 | On the list | Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous | Policies naming 38206 |
| 38232 | On the list | Bone marrow harvesting for transplantation; autologous | Policies naming 38232 |
| 38240 | On the list | Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic transplantation per donor | Policies naming 38240 |
| 38241 | On the list | Hematopoietic progenitor cell (HPC); autologous transplantation | Policies naming 38241 |
| 40223 | Not listed | Policies naming 40223 | |
| 44193 | Not listed | Policies naming 44193 | |
| 44444 | Not listed | Policies naming 44444 | |
| 45040 | Not listed | Policies naming 45040 | |
| 46204 | Not listed | Policies naming 46204 | |
| 47135 | On the list | Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age | Policies naming 47135 |
| 48554 | On the list | Transplantation of pancreatic allograft | Policies naming 48554 |
| 50360 | On the list | Renal allotransplantation, implantation of graft; without recipient nephrectomy | Policies naming 50360 |
| 54342 | Not listed | Policies naming 54342 | |
| 55555 | Not listed | Policies naming 55555 | |
| 60007 | Not listed | Policies naming 60007 | |
| 60197 | Not listed | Policies naming 60197 | |
| 70022 | Not listed | Policies naming 70022 | |
| 71010 | Not listed | Policies naming 71010 | |
| 72911 | Not listed | Policies naming 72911 | |
| 73651 | Not listed | Policies naming 73651 | |
| 76376 | On the list | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation | Policies naming 76376 |
| 76377 | On the list | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation | Policies naming 76377 |
| 77038 | Not listed | Policies naming 77038 | |
| 89502 | Not listed | Policies naming 89502 | |
| 90013 | Not listed | Policies naming 90013 | |
| 90060 | Not listed | Policies naming 90060 | |
| 90747 | Not listed | Policies naming 90747 | |
| 90935 | Not listed | Policies naming 90935 | |
| 90937 | Not listed | Policies naming 90937 | |
| 90945 | Not listed | Policies naming 90945 | |
| 90947 | Not listed | Policies naming 90947 | |
| 90989 | Not listed | Policies naming 90989 | |
| 90993 | Not listed | Policies naming 90993 | |
| 90999 | Not listed | Policies naming 90999 | |
| 91365 | Not listed | Policies naming 91365 | |
| 91367 | Not listed | Policies naming 91367 | |
| 92160 | Not listed | Policies naming 92160 | |
| 92420 | Not listed | Policies naming 92420 | |
| 92825 | Not listed | Policies naming 92825 | |
| 94105 | Not listed | Policies naming 94105 | |
| 94612 | Not listed | Policies naming 94612 | |
| 95000 | Not listed | Policies naming 95000 | |
| 95814 | Not listed | Policies naming 95814 | |
| 95927 | Not listed | Policies naming 95927 | |
| 96002 | Not listed | Policies naming 96002 | |
| 96360 | Not listed | Policies naming 96360 | |
| 96365 | Not listed | Policies naming 96365 | |
| 96366 | Not listed | Policies naming 96366 | |
| 96368 | Not listed | Policies naming 96368 | |
| 96374 | Not listed | Policies naming 96374 | |
| 96376 | Not listed | Policies naming 96376 | |
| 96379 | Not listed | Policies naming 96379 | |
| 96401 | Not listed | Policies naming 96401 | |
| 96402 | Not listed | Policies naming 96402 | |
| 96405 | Not listed | Policies naming 96405 | |
| 96406 | Not listed | Policies naming 96406 | |
| 96409 | Not listed | Policies naming 96409 | |
| 96411 | Not listed | Policies naming 96411 | |
| 96413 | Not listed | Policies naming 96413 | |
| 96415 | Not listed | Policies naming 96415 | |
| 96417 | Not listed | Policies naming 96417 | |
| 96446 | Not listed | Policies naming 96446 | |
| 96450 | Not listed | Policies naming 96450 | |
| 99001 | Not listed | Policies naming 99001 | |
| 99281 | Not listed | Policies naming 99281 | |
| 99282 | Not listed | Policies naming 99282 | |
| 99283 | Not listed | Policies naming 99283 | |
| 99284 | Not listed | Policies naming 99284 | |
| 99285 | Not listed | Policies naming 99285 | |
| C8957 | Not listed | Policies naming C8957 | |
| G0001 | Not listed | Policies naming G0001 | |
| G0151 | Not listed | Policies naming G0151 | |
| G0156 | Not listed | Policies naming G0156 | |
| G0380 | Not listed | Policies naming G0380 | |
| G0381 | Not listed | Policies naming G0381 | |
| G0382 | Not listed | Policies naming G0382 | |
| G0383 | Not listed | Policies naming G0383 | |
| G0384 | Not listed | Policies naming G0384 | |
| J0692 | Not listed | Policies naming J0692 | |
| J0882 | On the list | Darbepoetin Alfa (Aranesp) | Policies naming J0882 |
| J2248 | Not listed | Policies naming J2248 | |
| J2550 | Not listed | Policies naming J2550 | |
| J3490 | On the list | Unclassified drugs or biologicals [when specified as eladocagene exuparvovec-tneq (Kebilidi)] or [when specified as an ocular gene therapy agent other than voretigene neparvovec-rzyl (Luxturna)] or [when specified as elivaldogene autotemcel (Skysona)] or [when specified as etuvetidigene autotemcel (Waskyra)] or [when specified as a gene therapy for hemophilia other than Hemgenix, Beqvez, or Roctavian] | Policies naming J3490 |
| J7599 | Not listed | Policies naming J7599 | |
| J7699 | Not listed | Policies naming J7699 | |
| J9999 | On the list | Lifileucel (Amtagvi) | Policies naming J9999 |
| L8690 | On the list | Auditory osseointegrated device, includes all internal and external components | Policies naming L8690 |
| L8699 | On the list | Prosthetic implant, not otherwise specified [when specified as hybrid cochlear device, including all internal and external components] or [when describing replacement components of an auditory brain stem implant] or [when specified as a hyaluronic acid gel agent such as Juvederm or Restylane] or [when describing a prefabricated, custom-fitted auricular implant] or [when describing a custom-fabricated auricular implant] or [when specified as testicular or penile prosthesis] | Policies naming L8699 |
| P9012 | Not listed | Policies naming P9012 | |
| P9021 | Not listed | Policies naming P9021 | |
| P9022 | Not listed | Policies naming P9022 | |
| P9023 | Not listed | Policies naming P9023 | |
| P9038 | Not listed | Policies naming P9038 | |
| P9039 | Not listed | Policies naming P9039 | |
| Q0081 | Not listed | Policies naming Q0081 | |
| Q4081 | On the list | Epoetin alfa (for ESRD on dialysis) (Epogen, Procrit) | Policies naming Q4081 |
| S2900 | Not listed | Policies naming S2900 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list