Anthem Blue Cross Blue Shield of California policy
Anthem Blue Cross Professional Provider Manual
Anthem Blue Cross Professional Provider Manual is a public Anthem Blue Cross Blue Shield of California policy (effective Jul 6, 2015). It lists 105 CPT or HCPCS codes, 15 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
- Jul 6, 2015
- 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 |
|---|---|---|---|
| 00004 | Not listed | Policies naming 00004 | |
| 00005 | Not listed | Policies naming 00005 | |
| 00100 | Not listed | Policies naming 00100 | |
| 0188T | Not listed | Policies naming 0188T | |
| 0189T | Not listed | Policies naming 0189T | |
| 01999 | Not listed | Policies naming 01999 | |
| 06492 | Not listed | Policies naming 06492 | |
| 10169 | Not listed | Policies naming 10169 | |
| 10940 | Not listed | Policies naming 10940 | |
| 12211 | Not listed | Policies naming 12211 | |
| 12345 | Not listed | Policies naming 12345 | |
| 13550 | Not listed | Policies naming 13550 | |
| 20830 | Not listed | Policies naming 20830 | |
| 21555 | Not listed | Policies naming 21555 | |
| 2310A | Not listed | Policies naming 2310A | |
| 2310B | Not listed | Policies naming 2310B | |
| 24011 | Not listed | Policies naming 24011 | |
| 2420A | Not listed | Policies naming 2420A | |
| 27503 | Not listed | Policies naming 27503 | |
| 30326 | Not listed | Policies naming 30326 | |
| 31193 | Not listed | Policies naming 31193 | |
| 31904 | Not listed | Policies naming 31904 | |
| 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 | |
| 44193 | Not listed | Policies naming 44193 | |
| 44604 | Not listed | Policies naming 44604 | |
| 45040 | Not listed | Policies naming 45040 | |
| 45678 | Not listed | Policies naming 45678 | |
| 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 | |
| 59025 | Not listed | Policies naming 59025 | |
| 60007 | Not listed | Policies naming 60007 | |
| 70000 | Not listed | Policies naming 70000 | |
| 70022 | Not listed | Policies naming 70022 | |
| 70470 | On the list | CT head or brain; w/o contrast followed by contrast | Policies naming 70470 |
| 71250 | On the list | CT thorax; w/o contrast | Policies naming 71250 |
| 77280 | Not listed | Policies naming 77280 | |
| 77402 | On the list | Radiation treatment delivery, > 1 MeV; simple | Policies naming 77402 |
| 80203 | Not listed | Policies naming 80203 | |
| 81003 | Not listed | Policies naming 81003 | |
| 85025 | Not listed | Policies naming 85025 | |
| 89508 | Not listed | Policies naming 89508 | |
| 90013 | Not listed | Policies naming 90013 | |
| 90060 | Not listed | Policies naming 90060 | |
| 90801 | Not listed | Policies naming 90801 | |
| 90802 | Not listed | Policies naming 90802 | |
| 90804 | Not listed | Policies naming 90804 | |
| 90809 | Not listed | Policies naming 90809 | |
| 90832 | Not listed | Policies naming 90832 | |
| 90833 | Not listed | Policies naming 90833 | |
| 90834 | Not listed | Policies naming 90834 | |
| 90836 | Not listed | Policies naming 90836 | |
| 90847 | Not listed | Policies naming 90847 | |
| 90853 | Not listed | Policies naming 90853 | |
| 90862 | Not listed | Policies naming 90862 | |
| 91362 | Not listed | Policies naming 91362 | |
| 91365 | Not listed | Policies naming 91365 | |
| 91367 | Not listed | Policies naming 91367 | |
| 91470 | Not listed | Policies naming 91470 | |
| 92150 | Not listed | Policies naming 92150 | |
| 92160 | Not listed | Policies naming 92160 | |
| 92490 | Not listed | Policies naming 92490 | |
| 92825 | Not listed | Policies naming 92825 | |
| 95000 | Not listed | Policies naming 95000 | |
| 95814 | Not listed | Policies naming 95814 | |
| 95817 | Not listed | Policies naming 95817 | |
| 95825 | Not listed | Policies naming 95825 | |
| 95927 | Not listed | Policies naming 95927 | |
| 96002 | Not listed | Policies naming 96002 | |
| 96201 | Not listed | Policies naming 96201 | |
| 98966 | Not listed | Policies naming 98966 | |
| 98968 | Not listed | Policies naming 98968 | |
| 98969 | Not listed | Policies naming 98969 | |
| 99070 | Not listed | Policies naming 99070 | |
| 99199 | On the list | 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] | Policies naming 99199 |
| 99201 | Not listed | Policies naming 99201 | |
| 99213 | Not listed | Policies naming 99213 | |
| 99214 | Not listed | Policies naming 99214 | |
| 99215 | Not listed | Policies naming 99215 | |
| 99221 | Not listed | Policies naming 99221 | |
| 99241 | Not listed | Policies naming 99241 | |
| 99245 | Not listed | Policies naming 99245 | |
| 99441 | Not listed | Policies naming 99441 | |
| 99443 | Not listed | Policies naming 99443 | |
| 99444 | Not listed | Policies naming 99444 | |
| A0999 | On the list | Unlisted ambulance service | Policies naming A0999 |
| G0406 | Not listed | Policies naming G0406 | |
| G0407 | Not listed | Policies naming G0407 | |
| G0408 | Not listed | Policies naming G0408 | |
| G0425 | Not listed | Policies naming G0425 | |
| G0426 | Not listed | Policies naming G0426 | |
| G0427 | Not listed | Policies naming G0427 | |
| G9002 | Not listed | Policies naming G9002 | |
| J0610 | Not listed | Policies naming J0610 | |
| Q3014 | Not listed | Policies naming Q3014 | |
| T1014 | Not listed | Policies naming T1014 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list