CurrentAnthemPolicy N/A

Anthem California Precertification / Reviewed-by Anthem Code List (partial)

Lists CPT/HCPCS/U/other codes that Anthem (and delegated vendors Carelon/CarelonRx) review or prior authorize for California commercial members; includes submission instructions (photos, mental health letters, CT reports), transplant and behavioral health contact points, and notes California SB 535 removing prior authorization for biomarker testing in advanced/metastatic (stage 3/4) cancer.

Policy Summary

PayerAnthem

PolicyAnthem California Precertification / Reviewed-by Anthem Code List (partial)

Policy CodePolicy N/A

Change TypeOperational code list (no material change)

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility and benefits and submit required documentation (photos, mental health letters, CT reports) to the responsible reviewer (Anthem or Carelon/CarelonRx) per the code comments.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this brief — the document is a code list and operational guidance; no policy changes were reported.

CarelonResponsible party for most codes

Transgender-specificCodes with transgender surgery documentation

SB 535SB 535 biomarker PA removal

150+Approx. codes in extract

Transplant / BehavioralSpecial contacts called out

Policy Overview & Scope

Precertification / Review Rules & Routing

General Precertification/Review Rules and Applicability

General precertification/review rules and applicability. Preserve AND/OR logic for member/program applicability and SB 535 exception.

all of the following apply to precertification and review routing:

any of the following member/program applicability rules:

- Local fully-insured Anthem members and select ASO (self‑insured) members whose services are medically managed as part of a purchased program are subject to the precertification and clinical review rules described herein.

- Does NOT apply to HMO, BlueCard, Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program (FEP).

Policy Summary

PayerAnthem

PolicyAnthem California Precertification / Reviewed-by Anthem Code List (partial)

Policy CodePolicy N/A

Change TypeOperational code list (no material change)

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Operational mapping of code review/authorization responsibilities

Operational mapping: use this decision tree to determine which organization (Anthem vs Carelon/CarelonRx) is responsible for review/authorization and required contact points.

all of the following operational rules:

any of the following responsibility determination steps:

- Step 1: Determine member/product applicability (see General Precertification/Review Rules and Applicability).

- Step 2: Determine code-level assignment. If code is listed in the "Reviewed by Anthem" code lists (behavioral health codes, specified surgical/anesthesia/plastic/transplant codes, maternity admission thresholds, unlisted/NOC codes when indicated), route to Anthem for review.

- Step 3: If code is managed by Carelon Medical Benefits Management (examples: oncology, musculoskeletal, monitored anesthesia for GI procedures, site-of-care for certain surgical services for local fully‑insured and select ASO members), route to Carelon.

- Step 4: For pharmacy/medication requests, route to CarelonRx per pharmacy clinical criteria and the CarelonRx website.

- Step 5: If responsibility is unclear or member/product indicates special program purchase, verify routing by contacting the number on the member ID card or the Anthem/Carelon provider portals.

note:

- Behavioral health services (inpatient and outpatient) are reviewed by Anthem — contact Behavioral Health at the number on the member's ID card.

- Transplant-related anesthesia and transplant recipient procedure codes (e.g., 00580, 00796) are reviewed by Anthem; contact Anthem Transplant unit at 888-574-7215.

- For transgender-related plastic surgery codes listed under Anthem responsibility (multiple 15xxx and 17xxx codes and select unlisted codes), submit required mental health letters, photos, and plastics evaluations via Availity as noted in the specific code comments.

threshold:

- Maternity inpatient admissions: vaginal >2 days or cesarean >4 days require Anthem review/prior authorization.

Code Lists (grouped by category / responsible party)

Reviewed-by Anthem (require review/prior authorization) - Plastic/Reconstructive/Transgender-related and cosmetic/reconstructive codes (partial)CPT

00580	Anesthesia for heart transplant or heart/lung transplant
00796	Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; liver transplant (recipient)
15756	Free muscle or myocutaneous flap with microvascular anastomosis [when specified as a lymph node tissue transfer procedure]
15769	Grafting of autologous soft tissue; other, harvested by direct excision (eg, fat, dermis, fascia)
15825	Rhytidectomy; neck with platysmal tightening
15828	Rhytidectomy; cheek, chin, and neck
15829	Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap
15832	Excision; excessive skin and subcutaneous tissue (includes lipectomy); thigh
15833	Excision; excessive skin and subcutaneous tissue (includes lipectomy); leg
15834	Excision; excessive skin and subcutaneous tissue (includes lipectomy); hip

1–10 of 134

1/14

Gynecologic / Hysterectomy and related proceduresCPT

58180	Excision of ovary, complex
58200	Total abdominal hysterectomy
58210	Total vaginal hysterectomy
58240	Radical hysterectomy
58267	Hysterectomy with removal of adnexa
58275	Hysterectomy for pelvic organ prolapse
58280	Hysterectomy with repair
58285	Hysterectomy, other
58548	Laparoscopic supracervical hysterectomy
58552	Laparoscopic total hysterectomy with removal of tube/ovary

1–10 of 22

1/3

Neurosurgery / Neurostimulation / Intracranial proceduresCPT

61630	Craniotomy for tumor or lesion
61635	Craniotomy with neurostimulation device implantation
61736	Stereotactic implantation of neurostimulator lead
61737	Stereotactic implantation, multiple leads
61850	Insertion or replacement of neurostimulator pulse generator
61860	Stereotactic ablative procedures
61863	Stereotactic placement, cranial
61864	Placement of cranial electrode array
61867	Stereotactic lesioning
61868	Other cranial neuro procedures

1–10 of 13

1/2

Imaging / Radiology / Nuclear / MRI / Ultrasound unlisted codesCPT

76125	Unlisted radiology procedure
76496	Unlisted CT procedure
76498	Unlisted MRI procedure
76499	Other unlisted imaging procedure
78999	Unlisted abdomen imaging
93356	Contrast echocardiography, unlisted

Behavioral Healthmixed

Various	Behavioral Health Services - Inpatient and Outpatient (contact Behavioral Health per member ID card)
90867	Family psychotherapy, conjoint psychotherapy with patient present, complex
90868	Group psychotherapy, per 30 minutes
90869	Other psychotherapy codes
90875	Family psychotherapy without the patient present
90876	Multiple-family group psychotherapy

Laboratory / Biomarkermixed

81490	Cancer genomic profiling (select)
81517	Molecular pathology procedure
81535	Oncology test
81536	Predictive biomarker testing
81538	Tumor profiling
81539	Companion diagnostic

Transplantmixed

00580	Anesthesia for heart transplant or heart/lung transplant (Contact Anthem Transplant unit 888-574-7215)
00796	Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; liver transplant (recipient) (Contact Anthem Transplant unit 888-574-7215)
33940	Heart/lung transplant related procedures

DME / DeviceHCPCS

A2022	Specialty device code example
E0481	Home ventilator supplies example
E1399	Durable medical equipment, miscellaneous

Ambulance / TransportHCPCS

A0430	Ambulance transport, basic life support
A0431	Ambulance transport, advanced life support
A0435	Air ambulance

Q-codes / S-codes / Home care / infusion S/T codesmixed

Q4311	Example Q-code (infusion)
S9500	Home infusion service code example
T2036	Home health aide (example)

Genetic testing U-codes / Novel lab (U / 00xxx / miscellaneous)mixed

0003M	Genetic test / novel lab code example
OO18M	Genetic assay (example)
O100T	Molecular pathology/proprietary test (example)
81479	Unlisted molecular pathology procedure (placeholder)

Other Unlisted / Miscellaneous (single-code examples consolidated)mixed

17999	Unlisted procedure; Skin, mucous membrane and subcutaneous tissue
19499	Unlisted procedure, breast
21270	Reconstruction, other head/neck (unlisted examples)
29999	Unlisted laparoscopic procedure
93799	Cardiac diagnostic unlisted

This is a partial extract. See full policy/code appendix for complete lists and exact per-code criteria/guideline references.

OpenPayer

Anthem California Precertification / Reviewed-by Anthem Code List (partial)

Policy Overview & Scope

Precertification / Review Rules & Routing

What Providers Must Do (submission, contacts, documentation)

Operational Billing Rules & Denial Risks

Code Lists (grouped by category / responsible party)

Key Terms & Abbreviations

Common Questions (Provider FAQs)

Document Revision Timeline