Anthem Blue Cross Blue Shield of California policy
Anthem Blue Cross HMO Provider Manual - 03/15/20 - 10/14/20
Anthem Blue Cross HMO Provider Manual - 03/15/20 - 10/14/20 is a public Anthem Blue Cross Blue Shield of California policy (effective Mar 15, 2020). It lists 49 CPT or HCPCS codes, 11 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 15, 2020
- Line of business
- Commercial
- 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 |
|---|---|---|---|
| 00001 | Not listed | Policies naming 00001 | |
| 06492 | Not listed | Policies naming 06492 | |
| 10199 | Not listed | Policies naming 10199 | |
| 10940 | Not listed | Policies naming 10940 | |
| 12211 | Not listed | Policies naming 12211 | |
| 13550 | Not listed | Policies naming 13550 | |
| 20201 | Not listed | Policies naming 20201 | |
| 21215 | On the list | Graft, bone; mandible (includes obtaining graft) | Policies naming 21215 |
| 21555 | Not listed | Policies naming 21555 | |
| 23279 | Not listed | Policies naming 23279 | |
| 24011 | Not listed | Policies naming 24011 | |
| 27401 | Not listed | Policies naming 27401 | |
| 30326 | Not listed | Policies naming 30326 | |
| 30348 | Not listed | Policies naming 30348 | |
| 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 |
| 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 | |
| 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 |
| 60007 | Not listed | Policies naming 60007 | |
| 70022 | Not listed | Policies naming 70022 | |
| 89502 | Not listed | Policies naming 89502 | |
| 90013 | Not listed | Policies naming 90013 | |
| 90060 | Not listed | Policies naming 90060 | |
| 91365 | Not listed | Policies naming 91365 | |
| 91367 | Not listed | Policies naming 91367 | |
| 92160 | Not listed | Policies naming 92160 | |
| 92825 | Not listed | Policies naming 92825 | |
| 95814 | Not listed | Policies naming 95814 | |
| 95817 | Not listed | Policies naming 95817 | |
| 95927 | Not listed | Policies naming 95927 | |
| 96002 | Not listed | Policies naming 96002 | |
| E0000 | Not listed | Policies naming E0000 | |
| E9999 | Not listed | Policies naming E9999 | |
| L0000 | Not listed | Policies naming L0000 | |
| L4999 | Not listed | Policies naming L4999 | |
| L5000 | Not listed | Policies naming L5000 | |
| L9999 | Not listed | Policies naming L9999 | |
| V2623 | Not listed | Policies naming V2623 | |
| V2629 | Not listed | Policies naming V2629 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list