Anthem Blue Cross Blue Shield of California policy
SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures is a public Anthem Blue Cross Blue Shield of California policy (policy SURG.00023). It lists 30 CPT or HCPCS codes, 27 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
- Policy number
- SURG.00023
- 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 |
|---|---|---|---|
| 00011 | Not listed | Policies naming 00011 | |
| 00023 | Not listed | Policies naming 00023 | |
| 00132 | Not listed | Policies naming 00132 | |
| 11920 | On the list | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation | Policies naming 11920 |
| 11921 | On the list | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation | Policies naming 11921 |
| 11922 | On the list | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation | Policies naming 11922 |
| 15877 | On the list | Suction assisted lipectomy; trunk | Policies naming 15877 |
| 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 |
| 19316 | On the list | Mastopexy | Policies naming 19316 |
| 19318 | On the list | Breast reduction | Policies naming 19318 |
| 19325 | On the list | Breast augmentation with implant | Policies naming 19325 |
| 19328 | On the list | Removal of intact breast implant | Policies naming 19328 |
| 19330 | On the list | Removal of ruptured breast implant, including implant contents (e.g., saline, silicone gel) | Policies naming 19330 |
| 19340 | On the list | Insertion of breast implant on same day of mastectomy (i.e., immediate) | Policies naming 19340 |
| 19342 | On the list | Insertion or replacement of breast implant on separate day from mastectomy | Policies naming 19342 |
| 19350 | On the list | Nipple/areola reconstruction | Policies naming 19350 |
| 19355 | On the list | Correction of inverted nipples | Policies naming 19355 |
| 19357 | On the list | Tissue expander placement in breast reconstruction, including subsequent expansion(s) | Policies naming 19357 |
| 19361 | On the list | Breast reconstruction with latissimus dorsi flap | Policies naming 19361 |
| 19364 | On the list | Breast reconstruction with free flap (e.g., fTRAM, DIEP, SIEA, GAP flap) | Policies naming 19364 |
| 19367 | On the list | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap | Policies naming 19367 |
| 19368 | On the list | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging) | Policies naming 19368 |
| 19369 | On the list | Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap | Policies naming 19369 |
| 19380 | On the list | Revision of reconstructed breast (e.g., significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction) | Policies naming 19380 |
| 19396 | On the list | Preparation of moulage for custom breast implant | Policies naming 19396 |
| C1789 | On the list | Prosthesis, breast (implantable) | Policies naming C1789 |
| L8600 | On the list | Implantable breast prosthesis, silicone or equal | Policies naming L8600 |
| S2066 | On the list | Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral | Policies naming S2066 |
| S2067 | On the list | Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral | Policies naming S2067 |
| S2068 | On the list | Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral | Policies naming S2068 |
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