Anthem Blue Cross Blue Shield of California policy
CG-SURG-70 Gastric Electrical Stimulation
CG-SURG-70 Gastric Electrical Stimulation is a public Anthem Blue Cross Blue Shield of California policy (policy CG-SURG-70). It lists 16 CPT or HCPCS codes, 9 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-70
- 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 |
|---|---|---|---|
| 43647 | Not listed | Policies naming 43647 | |
| 43648 | Not listed | Policies naming 43648 | |
| 43659 | On the list | Unlisted laparoscopy procedure, stomach [when specified as gastric plication (laparoscopic greater curvature plication [LGCP]) with or without gastric banding, sleeve gastroplasty, or mini-gastric bypass procedure] | Policies naming 43659 |
| 43881 | Not listed | Policies naming 43881 | |
| 43882 | Not listed | Policies naming 43882 | |
| 43999 | On the list | Unlisted procedure, stomach [when specified as bariatric arterial embolization, endoluminal gastric restrictive surgery, placement of intragastric balloon device, or aspiration therapy] or [when specified as transendoscopic (peroral) gastric myotomy G-POEM] | Policies naming 43999 |
| 64590 | On the list | Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver [when specified as phrenic nerve stimulator for CG-MED-79] or [when specified as sacral nerve stimulator for CG-SURG-95] | Policies naming 64590 |
| 64595 | On the list | Revision or removal of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array [when specified as sacral nerve stimulator] | Policies naming 64595 |
| 95980 | Not listed | Policies naming 95980 | |
| 95981 | Not listed | Policies naming 95981 | |
| 95982 | Not listed | Policies naming 95982 | |
| C1767 | On the list | Generator, neurostimulator (implantable), nonrechargeable | Policies naming C1767 |
| C1778 | On the list | Lead, neurostimulator (implantable) | Policies naming C1778 |
| L8679 | On the list | Neurostimulator Implantation - Implantable neurostimulator, pulse generator, any type | Policies naming L8679 |
| L8680 | On the list | Neurostimulator Implantation - Implantable heurostimulator electrode, each | Policies naming L8680 |
| L8688 | On the list | Implantable neurostimulator pulse generator, dual array, non- rechargeable, includes extension | Policies naming L8688 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list