Anthem Blue Cross Blue Shield of California policy
MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications is a public Anthem Blue Cross Blue Shield of California policy (policy MED.00057). It lists 6 CPT or HCPCS codes, 6 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
- MED.00057
- 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 |
|---|---|---|---|
| 0071T | On the list | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue | Policies naming 0071T |
| 0072T | On the list | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue | Policies naming 0072T |
| 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 |
| 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 |
| 61715 | On the list | Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation of target, intracranial, including stereotactic navigation and frame placement, when performed | Policies naming 61715 |
| C9734 | On the list | Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with or without magnetic resonance (MR) guidance | Policies naming C9734 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list