Anthem Blue Cross Blue Shield of California policy
Global Surgical Package- Professional
Global Surgical Package- Professional is a public Anthem Blue Cross Blue Shield of California policy (policy C-08007, effective Jul 1, 2024). It lists 159 CPT or HCPCS codes, 51 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-08007
- Effective
- Jul 1, 2024
- 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 |
|---|---|---|---|
| 0335T | On the list | Insertion of sinus tarsi implant | Policies naming 0335T |
| 0343T | Not listed | Policies naming 0343T | |
| 0344T | Not listed | Policies naming 0344T | |
| 0345T | On the list | Transcatheter mitral valve repair percutaneous approach via the coronary sinus | Policies naming 0345T |
| 0440T | On the list | Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve | Policies naming 0440T |
| 0441T | On the list | Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve | Policies naming 0441T |
| 0442T | On the list | Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (e.g., brachial plexus, pudendal nerve) | Policies naming 0442T |
| 0444T | Not listed | Policies naming 0444T | |
| 0445T | Not listed | Policies naming 0445T | |
| 0446T | Not listed | Policies naming 0446T | |
| 0447T | Not listed | Policies naming 0447T | |
| 0448T | Not listed | Policies naming 0448T | |
| 0466T | Not listed | Policies naming 0466T | |
| 0467T | Not listed | Policies naming 0467T | |
| 0468T | Not listed | Policies naming 0468T | |
| 0510T | On the list | Removal of sinus tarsi implant | Policies naming 0510T |
| 0511T | On the list | Removal and reinsertion of sinus tarsi implant | Policies naming 0511T |
| 0567T | Not listed | Policies naming 0567T | |
| 0568T | Not listed | Policies naming 0568T | |
| 0571T | On the list | Insertion or replacement of implantable cardioverter- defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed | Policies naming 0571T |
| 0572T | On the list | Insertion of substernal implantable defibrillator electrode | Policies naming 0572T |
| 0573T | On the list | Removal of substernal implantable defibrillator electrode | Policies naming 0573T |
| 0574T | On the list | Repositioning of previously implanted substernal implantable defibrillator-pacing electrode | Policies naming 0574T |
| 0580T | On the list | Removal of substernal implantable defibrillator pulse generator only | Policies naming 0580T |
| 0583T | Not listed | Policies naming 0583T | |
| 0585T | On the list | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; laparoscopic | Policies naming 0585T |
| 0588T | Not listed | Policies naming 0588T | |
| 0594T | Not listed | Policies naming 0594T | |
| 0596T | On the list | Temporary female intraurethral valve-pump (i.e., voiding prosthesis); initial insertion, including urethral measurement [inFlow system] | Policies naming 0596T |
| 0597T | On the list | Temporary female intraurethral valve-pump (i.e., voiding prosthesis); replacement [inFlow system] | Policies naming 0597T |
| 0600T | On the list | Ablation, irreversible electroporation; 1 or more tumors per organ, other than liver or prostate, including imaging guidance, when performed, percutaneous | Policies naming 0600T |
| 0601T | On the list | Ablation, irreversible electroporation; 1 or more tumors, including fluoroscopic and ultrasound guidance, when performed, open | Policies naming 0601T |
| 0614T | On the list | Removal and replacement of substernal implantable defibrillator pulse generator | Policies naming 0614T |
| 0619T | Not listed | Policies naming 0619T | |
| 0621T | Not listed | Policies naming 0621T | |
| 0622T | Not listed | Policies naming 0622T | |
| 0627T | On the list | Percutaneous injection of allogeneic cellular and/or tissue- based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level | Policies naming 0627T |
| 0629T | On the list | Percutaneous injection of allogeneic cellular and/or tissue- based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level | Policies naming 0629T |
| 0644T | Not listed | Policies naming 0644T | |
| 0647T | Not listed | Policies naming 0647T | |
| 0655T | On the list | Transperineal focal laser ablation of malignant prostate tissue, including transrectal imaging guidance, with MR-fused images or other enhanced ultrasound imaging | Policies naming 0655T |
| 0660T | Not listed | Policies naming 0660T | |
| 0661T | Not listed | Policies naming 0661T | |
| 0672T | On the list | Endovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence | Policies naming 0672T |
| 0673T | On the list | Ablation, benign thyroid nodule(s), percutaneous, laser, including imaging guidance | Policies naming 0673T |
| 0677T | Not listed | Policies naming 0677T | |
| 0679T | Not listed | Policies naming 0679T | |
| 0680T | Not listed | Policies naming 0680T | |
| 0681T | Not listed | Policies naming 0681T | |
| 0682T | Not listed | Policies naming 0682T | |
| 0699T | Not listed | Policies naming 0699T | |
| 0714T | Not listed | Policies naming 0714T | |
| 0730T | Not listed | Policies naming 0730T | |
| 0737T | Not listed | Policies naming 0737T | |
| 08007 | Not listed | Policies naming 08007 | |
| 10060 | Not listed | Policies naming 10060 | |
| 10061 | Not listed | Policies naming 10061 | |
| 10140 | Not listed | Policies naming 10140 | |
| 10160 | Not listed | Policies naming 10160 | |
| 10180 | Not listed | Policies naming 10180 | |
| 15999 | Not listed | Policies naming 15999 | |
| 17999 | On the list | Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as other abdominoplasty, excision excessive skin and subcutaneous tissue, including lipectomy, of abdomen] or [when specified as permanent hair removal by laser] or [when specified as implantation of biologic implants for soft tissue reinforcement in tissues other than breast and trunk] or [when specified as aesthetic flat chest closure or chest wall reconstruction after breast surgery] or [when specified as laser treatment of onychomycosis] or [when specified as percutaneous ultrasound ablation of subcutaneous tissue] or [when specified as application of prademagene zamikeracel (Zevaskyn) genetically engineered autologous cell therapy] or [when specified as harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 17999 |
| 19499 | On the list | Unlisted procedure, breast [when specified as destruction of breast tissue by high intensity focused ultrasound] or [when specified as radiofrequency or microwave ablation or laser ablation of breast tumor(s)] or [when specified as catheter lavage of a mammary duct or fiberoptic ductoscopy] | Policies naming 19499 |
| 20999 | On the list | Unlisted procedure, musculoskeletal system, general [when specified as high intensity focused ultrasound for pain palliation for bone metastases] or [No specific code for surgery using Coblation technology] or [when specified as radiofrequency or pulsed radiofrequency treatment of trigger points] or [when specified as percutaneous ultrasonic ablation of soft tissue] or [when specified as harvesting and injection of bone marrow aspirate concentrate or harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 20999 |
| 21089 | Not listed | Policies naming 21089 | |
| 21299 | Not listed | Policies naming 21299 | |
| 21499 | Not listed | Policies naming 21499 | |
| 21899 | Not listed | Policies naming 21899 | |
| 22899 | On the list | Unlisted procedure, spine [when specified as percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) or intradiscal biacuplasty (IDB)] or [when specified as a percutaneous or endoscopic procedure for decompression for example DTRAX cage procedure] or [when specified as insertion of a dynamic intervertebral pedicle-based stabilization device] or [when specified as pre-sacral interbody arthrodesis lumbar. L4-L5 interspace with instrumentation, or pre-sacral interbody arthrodesis L4-L5 or L5-S1 interspace without instrumentation] or [when specified as insertion of a non-pedicle interspinous process fixation device] | Policies naming 22899 |
| 22999 | On the list | Unlisted procedure, abdomen, musculoskeletal system [when specified as repair of diastasis recti] | Policies naming 22999 |
| 23004 | Not listed | Policies naming 23004 | |
| 23929 | Not listed | Policies naming 23929 | |
| 24999 | Not listed | Policies naming 24999 | |
| 25999 | Not listed | Policies naming 25999 | |
| 26989 | Not listed | Policies naming 26989 | |
| 27299 | Not listed | Policies naming 27299 | |
| 27599 | On the list | Unlisted procedure, femur or knee [when specified as implantation of a medial knee implanted shock absorber] or [when specified as implantation of RETHYMIC into quadriceps muscle] | Policies naming 27599 |
| 27899 | Not listed | Policies naming 27899 | |
| 28899 | On the list | Unlisted procedure, foot or toes [when specified as cryoablation of plantar fasciitis or plantar fibroma] or [when specified as subtalar arthroereisis] | Policies naming 28899 |
| 29999 | On the list | Unlisted procedure, arthroscopy [when specified as a tendon repair using BioBrace implant] or [when specified as thermal capsulorrhaphy of shoulder; elbow, wrist, hip, knee or ankle] or [when specified as surgery using Coblation technology] | Policies naming 29999 |
| 30999 | On the list | Unlisted procedure, nose [when specified as rhinophototherapy, intranasal application of ultraviolet and visible light] or [when specified as nasal valve suspension by any method] or [when specified as minimally invasive treatment of the posterior nasal nerve, for example using cryotherapy, radiofrequency therapy or laser] | Policies naming 30999 |
| 31299 | On the list | Unlisted procedure, accessory sinuses [when specified as application of self-expanding absorptive sinus ostial dilator (for example, SinuSys Vent-OS Sinus Dilation System)] or [when specified as insertion of a drug-eluting sinus stent] | Policies naming 31299 |
| 32999 | Not listed | Policies naming 32999 | |
| 33999 | On the list | Unlisted procedure, cardiac surgery [when specified as percutaneous transmyocardial revascularization] or [when specified as transmyocardial transcatheter closure of ventricular septal defect, with implant, including cardiopulmonary bypass if performed] or [when specified as transcatheter replacement of tricuspid heart valve] or [when specified as autologous cell therapy for damaged myocardium, including harvesting and preparation of cells] or [when specified as use of a portable normothermic organ perfusion system for heart transplantation] | Policies naming 33999 |
| 34841 | Not listed | Policies naming 34841 | |
| 34842 | Not listed | Policies naming 34842 | |
| 34843 | Not listed | Policies naming 34843 | |
| 34844 | Not listed | Policies naming 34844 | |
| 34845 | Not listed | Policies naming 34845 | |
| 34846 | Not listed | Policies naming 34846 | |
| 34847 | Not listed | Policies naming 34847 | |
| 34848 | Not listed | Policies naming 34848 | |
| 36299 | Not listed | Policies naming 36299 | |
| 37501 | Not listed | Policies naming 37501 | |
| 37799 | On the list | Unlisted procedure, vascular surgery [when specified as percutaneous hepatic perfusion delivery of intra-arterial high dose melphalan HEPZATO] or [when specified as COMPASS protocol, endoluminal cryoablation, or coil embolization of varicose veins] or [when specified as extracorporeal carbon dioxide removal] | Policies naming 37799 |
| 38129 | Not listed | Policies naming 38129 | |
| 38589 | Not listed | Policies naming 38589 | |
| 38999 | On the list | Unlisted procedure, hemic or lymphatic system [when specified as use of an ex-vivo expansion of cord blood stem cell product such as omidubicel (Omisirge)] or [when specified as bone marrow cell therapy or stem cell therapy such as IM, IV or IA for peripheral vascular disease] | Policies naming 38999 |
| 39499 | Not listed | Policies naming 39499 | |
| 39599 | Not listed | Policies naming 39599 | |
| 40799 | Not listed | Policies naming 40799 | |
| 40899 | Not listed | Policies naming 40899 | |
| 41599 | Not listed | Policies naming 41599 | |
| 41899 | Not listed | Policies naming 41899 | |
| 42299 | On the list | Unlisted procedure, palate, uvula [when specified as any of the following: Cautery-assisted palatal stiffening (CAPSO); Coblation; Palatal implants; Injection snoreplasty; The Pillar™ system] or [when specified as transpalatal advancement pharyngoplasty (TAP)] | Policies naming 42299 |
| 42699 | Not listed | Policies naming 42699 | |
| 42999 | Not listed | Policies naming 42999 | |
| 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 |
| 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 |
| 44238 | Not listed | Policies naming 44238 | |
| 44799 | Not listed | Policies naming 44799 | |
| 44899 | Not listed | Policies naming 44899 | |
| 44979 | Not listed | Policies naming 44979 | |
| 45499 | Not listed | Policies naming 45499 | |
| 46999 | On the list | Unlisted procedure, anus [when specified as perianal injection of autologous adipose-derived regenerative cells, e.g., for fistulizing Crohn’s disease] or [when specified as delivery of thermal energy to the muscle of the anal canal (e.g., for fecal incontinence)] or [when specified as anal sphincteroplasty for incontinence with implantation of an artificial sphincter] | Policies naming 46999 |
| 47379 | Not listed | Policies naming 47379 | |
| 47399 | On the list | Unlisted procedure, liver [when specified as histotripsy of nonmalignant lesion of liver] | Policies naming 47399 |
| 47579 | Not listed | Policies naming 47579 | |
| 47999 | Not listed | Policies naming 47999 | |
| 48999 | On the list | Unlisted procedure, pancreas [when specified as cryosurgical or radiofrequency ablation of pancreas tumor(s)] | Policies naming 48999 |
| 49329 | Not listed | Policies naming 49329 | |
| 49659 | Not listed | Policies naming 49659 | |
| 49999 | Not listed | Policies naming 49999 | |
| 50549 | Not listed | Policies naming 50549 | |
| 50949 | Not listed | Policies naming 50949 | |
| 51700 | Not listed | Policies naming 51700 | |
| 51999 | Not listed | Policies naming 51999 | |
| 53899 | On the list | Unlisted procedure, urinary system [when specified as transurethral MRI directional ultrasound ablation of prostate tissue (TULSA)] or [when specified as use of a portable normothermic organ perfusion system for kidney transplantation] | Policies naming 53899 |
| 55559 | Not listed | Policies naming 55559 | |
| 55899 | On the list | Unlisted procedure, male genital system [when specified as phalloplasty] or [when specified as image-guided focused ultrasound ablation of prostate tissue for non-oncologic indications, such as benign prostatic hyperplasia] or [when specified as intracavernous injection of autologous adipose- derived regenerative cells, e.g., for erectile dysfunction] or [when specified as nanoparticle thermal ablation] or [when specified as histotripsy of prostate tissue] | Policies naming 55899 |
| 58578 | On the list | Unlisted laparoscopy procedure, uterus [when specified as HALT procedure] | Policies naming 58578 |
| 58679 | Not listed | Policies naming 58679 | |
| 58999 | On the list | Unlisted procedure, female genital system (nonobstetrical) [when specified as any vaginal rejuvenation or tightening procedure for atrophy, including laser procedures such as MonaLisa Touch] or [when specified as cancer screening or identification using an optical detection system] or [when specified as image-guided percutaneous ablation by laser, bipolar electrodes, interstitial thermotherapy, cryotherapy, radiofrequency] | Policies naming 58999 |
| 59400 | Not listed | Policies naming 59400 | |
| 59410 | Not listed | Policies naming 59410 | |
| 59510 | Not listed | Policies naming 59510 | |
| 59515 | Not listed | Policies naming 59515 | |
| 59610 | Not listed | Policies naming 59610 | |
| 59614 | Not listed | Policies naming 59614 | |
| 59618 | Not listed | Policies naming 59618 | |
| 59622 | Not listed | Policies naming 59622 | |
| 59898 | Not listed | Policies naming 59898 | |
| 59899 | Not listed | Policies naming 59899 | |
| 60659 | Not listed | Policies naming 60659 | |
| 60699 | On the list | Unlisted procedure, endocrine system [when specified as cryosurgical or radiofrequency ablation of thyroid or adrenal tumor(s)] or [when specified as image-guided focused ultrasound ablation for non-oncologic indications] or [when specified as implantation of allogeneic processed thymus tissue-agdc (RETHYMIC)] | Policies naming 60699 |
| 64999 | On the list | Unlisted procedure, nervous system [when specified as implantation, revision, replacement, or removal of vagus nerve blocking neurostimulator electrode array or pulse generator at the esophagogastric junction] or [when specified as percutaneous neuromodulation therapy] or [when specified as introduction of Kebilidi into cranial cavity and brain] or [when specified as craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebellar] or [when specified as percutaneous decompression or laser procedures of cervical or thoracic spine] or [when specified as epiduroscopy] or [when specified as pulsed radiofrequency treatment] or [when specified as cooled or pulsed RF therapy (not destruction) to genicular nerve(s)] or [when specified as cryoneurolysis] or [when specified as nanoparticle thermal ablation] or [when specified as adrenal tissue, fetal mesencephalic tissue or fetal xenograft tissue transplant to brain] or [when specified as harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 64999 |
| 66999 | Not listed | Policies naming 66999 | |
| 67299 | Not listed | Policies naming 67299 | |
| 67599 | Not listed | Policies naming 67599 | |
| 67999 | Not listed | Policies naming 67999 | |
| 68399 | Not listed | Policies naming 68399 | |
| 68899 | Not listed | Policies naming 68899 | |
| 69399 | On the list | Unlisted procedure, external ear [when specified as other otoplasty] | Policies naming 69399 |
| 69799 | On the list | Unlisted procedure, middle ear [when specified as implantation of semi-implantable or fully implantable hearing aid] or [when specified as balloon dilation of eustachian tube, any approach] | Policies naming 69799 |
| 69949 | On the list | Unlisted procedure, inner ear [when specified as implantation of hybrid cochlear device] | Policies naming 69949 |
| 69979 | Not listed | Policies naming 69979 | |
| G0308 | Not listed | Policies naming G0308 | |
| G0309 | Not listed | Policies naming G0309 | |
| S2083 | Not listed | Policies naming S2083 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list