Anthem Blue Cross Blue Shield of California policy
Bundled Services and Supplies – Facility
Bundled Services and Supplies – Facility is a public Anthem Blue Cross Blue Shield of California policy (policy C-23001, effective Oct 1, 2026). It lists 39 CPT or HCPCS codes, 5 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) ↗
- Policy number
- C-23001
- Effective
- Oct 1, 2026
- 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 |
|---|---|---|---|
| 15851 | Not listed | Policies naming 15851 | |
| 76014 | Not listed | Policies naming 76014 | |
| 76019 | Not listed | Policies naming 76019 | |
| 76979 | Not listed | Policies naming 76979 | |
| 76983 | Not listed | Policies naming 76983 | |
| 77293 | Not listed | Policies naming 77293 | |
| 77387 | On the list | Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed | Policies naming 77387 |
| 87913 | Not listed | Policies naming 87913 | |
| 94760 | Not listed | Policies naming 94760 | |
| 94762 | Not listed | Policies naming 94762 | |
| 96521 | Not listed | Policies naming 96521 | |
| 96522 | Not listed | Policies naming 96522 | |
| 96523 | Not listed | Policies naming 96523 | |
| 97010 | Not listed | Policies naming 97010 | |
| 99070 | Not listed | Policies naming 99070 | |
| 99072 | Not listed | Policies naming 99072 | |
| 99190 | Not listed | Policies naming 99190 | |
| 99192 | Not listed | Policies naming 99192 | |
| A4206 | Not listed | Policies naming A4206 | |
| A4262 | Not listed | Policies naming A4262 | |
| A4265 | Not listed | Policies naming A4265 | |
| A9300 | Not listed | Policies naming A9300 | |
| A9900 | Not listed | Policies naming A9900 | |
| A9901 | Not listed | Policies naming A9901 | |
| A9999 | Not listed | Policies naming A9999 | |
| C1734 | On the list | Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to-bone (implantable) | Policies naming C1734 |
| C1762 | Not listed | Policies naming C1762 | |
| C1763 | On the list | Connective tissue, non-human (includes synthetic) [when specified as BioBrace Implant] | Policies naming C1763 |
| C1781 | Not listed | Policies naming C1781 | |
| C1889 | Not listed | Policies naming C1889 | |
| G0498 | Not listed | Policies naming G0498 | |
| G2211 | Not listed | Policies naming G2211 | |
| G6012 | Not listed | Policies naming G6012 | |
| G6014 | Not listed | Policies naming G6014 | |
| G6015 | Not listed | Policies naming G6015 | |
| G6017 | On the list | Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment | Policies naming G6017 |
| K1034 | Not listed | Policies naming K1034 | |
| 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 |
| T1040 | Not listed | Policies naming T1040 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list