Anthem Blue Cross Blue Shield of California policy
CG-SURG-118 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
CG-SURG-118 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) is a public Anthem Blue Cross Blue Shield of California policy (policy CG-SURG-118). It lists 8 CPT or HCPCS codes, 7 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-SURG-118
- Line of business
- Commercial
- 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 |
|---|---|---|---|
| 0253T | On the list | Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal space | Policies naming 0253T |
| 0449T | On the list | Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device [XEN Gel Stent] | Policies naming 0449T |
| 0450T | Not listed | Policies naming 0450T | |
| 0474T | On the list | Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space; each additional device [XEN Gel Stent] | Policies naming 0474T |
| 0671T | On the list | Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more | Policies naming 0671T |
| 66183 | On the list | Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach [when specified as Ex-PRESS Glaucoma Filtration Device] | Policies naming 66183 |
| 66989 | On the list | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (e.g., trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal | Policies naming 66989 |
| 66991 | On the list | aEpxptrraocaacphs, uolanre coart amraocret removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); with insertion of intraocular (e.g., trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more | Policies naming 66991 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list