CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Anthem Local PPO Precertification/Prior Authorization List — Plastic/Reconstructive Surgery codes

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List of procedure and unlisted CPT codes in plastic and reconstructive surgery that require precertification or prior authorization for Anthem Local PPO members; affects providers submitting precertification requests and billing for those services.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyAnthem Local PPO Precertification/Prior Authorization List — Plastic/Reconstructive Surgery codes

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit required supporting documentation (eg, photos, mental health letters, plastics evaluation, Haller Index/CT, sleep study, or other guideline-specified materials) via www.availity.com or contact the Anthem Transplant Unit when instructed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120+listed procedure and unlisted codes in this excerpt

Availitysubmission portal required

WPATHtransgender-related standards referenced

Haller Indexpectus repair imaging requirement

2026-04-01effective date

Coverage Criteria and Prior Authorization Rules

Prior Authorization with guideline-linked medical necessity

Covered when prior authorization is obtained per Anthem clinical guidelines referenced for each code

Authorization requirement: Provider obtains precertification/prior authorization and submits required documentation (e.g., photos, mental health letter, plastics evaluation, x-rays/tracings) as specified by the referenced guideline (e.g., ANC.00008, ANC.00009, SURG.00023, CG-SURG-84, WPATH Standards of Care)

Follow submission via Availity or contact specific units (e.g., Transplant Unit) when indicated

Authorization linked to external criteria/guidelines

Prior authorization required when procedures reference specific Anthem criteria or external standards

Submission requirements for ANC.00008/WPATH-linked codes: For codes that reference ANC.00008 and WPATH Standards of Care, authorization requires submission of photos; for transgender surgeries also submit a mental health letter and plastics evaluation via www.availity.com.

See ANC.00008 and WPATH Standards of Care for full medical necessity criteria

Submission requirements for CG-SURG-84: For codes that reference CG-SURG-84, submit x-rays and tracings via www.availity.com as part of the authorization request.

See CG-SURG-84 for detailed criteria

Pectus repair criteria: For pectus reconstructive repair (21740, 21742, 21743), submit Haller Index and CT report per ANC.00009 via Availity to support medical necessity.Haller Index (value per ANC.00009)

Exact numeric threshold is in ANC.00009 guideline

Transplant and cell therapy authorization criteria

Covered when services meet the referenced Anthem criteria/guidelines and prior authorization requirements

Transplant/CAR-T authorization: Procedures coded among listed transplant/CAR-T related CPT codes require prior authorization and adherence to referenced TRANS.* or CC-* criteria/guidelines; contact Anthem Transplant unit when comments direct.

See TRANS.* and CC-* guideline documents for medical necessity criteria

Bariatric surgery coverage criteria

Covered when ALL of the following are met per CG-SURG-83

Bariatric surgery documentation: BMI, nutritional consult, prior participation in weight management program, pre/post-op education and treatment plan, and medical/mental clearance submitted via Availity as specifiedBMI requirement per CG-SURG-83 (see guideline)

Exact numeric BMI thresholds are specified within CG-SURG-83, not in this excerpt

Gender-affirming surgery criteria

Covered when services meet WPATH Standards of Care referenced standards

Gender-affirming urethroplasty: Urethroplasty codes reference WPATH Standards of Care for criteria and are subject to those standards for coverage

Providers should follow WPATH guidance; link provided in comments

Covered with guideline-based prior authorization

These codes are subject to precertification and to referenced Anthem clinical guidelines or external standards:

Transplant codes: Codes such as 50325, 50327, 50328, 50329, 50340, 50360, 50365, 50547 require contacting Anthem Transplant unit and follow TRANS.* guidelines

Contact 888-574-7215; see TRANS.00011 / TRANS.00039 / TRANS.00038 as referenced

WPATH-referenced gender-affirming procedures: Multiple genital and gynecologic procedure codes reference WPATH Standards of Care and often require submission of 2 mental health letters via Availity or photos as noted

See https://wpath.org; specific submission instructions appear in code comments

Procedures referencing Anthem clinical guidelines: Several codes reference Anthem clinical guideline IDs (e.g., SURG.00010, SURG.00126, CG-SURG-106, CG-SURG-61, ANC.00009, MED.00057) and are subject to those guideline criteria for authorization

Providers must follow the specified guideline(s) referenced next to each code

General Prior Authorization Requirement

Codes are subject to authorization when they meet the referenced Anthem internal guidance

General prior authorization rule: Provider must obtain prior authorization for codes listed in the prior authorization list and submit documentation per the referenced Criteria/Guideline (e.g., SURG.00153 for many T-codes; LAB.00011, LAB.00031, LAB.00036, etc. for U-codes)

Specific inclusion/exclusion criteria are contained in the referenced internal guidelines

Power wheelchair / DME Prior Authorization

Covered when prior authorization per Anthem criteria is obtained:

Power mobility/DME prior auth: Provider must obtain prior authorization referencing CG-DME-31 for the listed K-codes (power wheelchairs/power-operated vehicles) and comply with any documentation/submission instructions.

See documentation module for Availity submission requirements

Amniotic membrane / allografts

Covered when prior authorization per SURG.00011 is obtained:

Amniotic/allograft prior auth: Providers must obtain prior authorization for listed Q-codes per SURG.00011; per-code per-square-centimeter billing applies.

Follow SURG.00011 criteria and submit required documentation via Availity if requested

Orthotics / Prosthetics Prior Authorization

Covered when documentation and prior authorization requirements are met:

Prosthetic/orthotic prior auth: Submit prosthetist evaluation, MD prescription and dollar amount via Availity for listed L-codes; some items (e.g., L8045) require photos. Follow referenced criteria (OR-PR.00006, OR-PR.00005, ANC.00008, SURG.00023 as applicable).

Transgender surgery references require WPATH documentation where indicated

Cellular therapy prior authorization

Covered when Anthem clinical criteria and transplant unit coordination are followed:

Cellular therapy prior auth: For listed Q-codes (CAR-T products), contact Anthem Transplant Unit and follow the referenced CC-xxxx criteria for authorization; phone contact provided in comments.

See comments for contact number

Breast reconstruction / WPATH-linked requirements

Covered when surgical criteria and WPATH documentation are met:

Breast reconstruction (including transgender surgery): S2066-S2068 reference SURG.00023 and WPATH Standards of Care; for transgender surgeries submit mental health letter and plastics evaluation via Availity.

Also provides WPATH link in comments

Code review / management

Covered when reviewed per the referenced Anthem/Carelon guideline(s) and documentation requirements

General mapping: Procedure code is eligible for precertification when submitted with required documentation and reviewed under the cited guideline (e.g., CG-SURG-127, SURG.00011, CG-SURG-123, SURG.00023).

Management may be by Carelon for fully insured/vendor eligible members; transgender surgeries require WPATH documentation.

Coverage mapping to referenced clinical guidelines

Codes are subject to medical necessity review according to the referenced criteria/guidelines and may require specified documentation

WPATH-related codes: Codes flagged with WPATH Standards of Care (e.g., many CG-SURG-123, CG-SURG-84 entries) require submission of mental health letter and plastics evaluation for transgender surgeries as part of authorization.

See referenced guideline for detailed medical necessity criteria.

ANC.00007-related cosmetic/aesthetic procedures: Procedures referencing ANC.00007 generally require photos for review; coverage determined per ANC.00007 criteria.

See ANC.00007 for specific cosmetic vs reconstructive determinations.

SURG.00129 orthognathic/airway procedures: SURG.00129-related codes may require sleep study results and x-rays/tracings; authorization per SURG.00129 and CG-SURG-84.

Submit sleep study and imaging as specified.

General prior authorization criteria

Prior authorization and supporting documentation required

Authorization requirements: When requesting prior authorization for listed surgical CPT codes, submit the documentation specified by the cited clinical guideline (e.g., SURG.00129 requires sleep study; CG-SURG-84 requires x-rays and tracings; transgender surgeries require WPATH-aligned mental health letter and plastics evaluation).

Management may be by Carelon for fully insured/vendor-program-eligible members or by Anthem for members not eligible for vendor programs.

Authorization management and guideline requirements

Covered when prior authorization is obtained per responsible party and referenced guideline

Management assignment: Prior authorization is required and is managed by Carelon for fully insured and vendor program eligible members; managed by Anthem for members not eligible for vendor programs and for certain categories (e.g., transgender surgeries).

See individual code comments for specifics (WPATH Standards, CG/MCG guidelines).

Guideline linkage: Specific codes reference criteria/guidelines (e.g., WPATH Standards of Care, CG-SURG-12, CG-MED-81, SURG.00077, CG-SURG-79, SURG.00142, etc.) which must be met for approval.

Provider must follow the named guideline for clinical criteria.

This prior-authorization list and its coverage criteria apply to Anthem Local PPO (Commercial) members; it does not apply to HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, or Federal Employee Program (FEP). Providers must verify member benefits and eligibility before submitting a precertification request because plan-level differences may affect whether precertification or clinical review is required.

Some entries on the list are unlisted (NOC) CPT codes or generic codes that are only considered when accompanied by a specified use; coverage or review depends on the stated specification and the referenced guideline. Examples include unlisted abdomen/musculoskeletal procedures (e.g., 22999) that are assessed only when described as a specific repair (see code comment linking to CG-SURG-99). When an unlisted code is used, providers should include the specific operative description and any guideline-referenced documentation with the prior authorization request.

The list identifies certain bariatric procedures that may be considered not medically necessary when performed using specific techniques (for example, 44238 is flagged when specified as bariatric procedures such as SADI‑S). Bariatric codes are governed by CG-SURG-83 and require submission of preoperative documentation (BMI, nutritional consult, prior weight‑management participation, education and clearance) via Availity for authorization.

Some unlisted female genital system codes (for example 58999) are shown with specific non‑routine uses (such as vaginal rejuvenation or laser procedures) and reference applicable guidelines (e.g., ANC.00009, SURG.00077). When an unlisted female genital code is submitted, providers must include the specified procedure description and any guideline‑required documentation.

Many codes on the list reference external or internal clinical guidelines (for example, ANC.00008, ANC.00009, CG‑SURG‑83, CG‑SURG‑84, SURG.00129, WPATH Standards of Care). The excerpt does not restate the full clinical inclusion/exclusion criteria from those guidelines; instead it requires that prior authorization requests be evaluated against the referenced guideline and that providers submit the documentation specified by that guideline (e.g., Haller Index/CT, sleep study, x‑rays/tracings, mental health letters, photos) via the Availity portal as directed.

Certain CPT entries include comments that limit how the code may be used or indicate a use‑limited context. For example, IV administration/additional infusion codes (e.g., 96367/96368/96372) have comments specifying use for IV antibiotic administration for Lyme Disease only (ICD‑10 A69.20‑A69.29). Providers should follow the per‑code comments when preparing authorization requests and claims.

A0888 is listed in the document as noncovered ambulance mileage, per mile. When billing ambulance mileage, providers should note this noncoverage designation and verify member benefits before submission.

Multiple IV antibiotic J‑codes in the list are noted with the comment: "For services specific to the administration of IV antibiotics for Lyme Disease ONLY (ICD‑10 Diagnosis codes A69.20‑A69.29)". Use of these injectable drug codes for other indications may not meet the stated code comment and could affect prior authorization or claims processing.

The excerpt is an administrative list of codes that require prior authorization or precertification; where applicable, each code entry is paired with a Criteria/Guideline reference. Providers must obtain authorization for the listed codes and submit the documentation required by the referenced guideline via Availity or follow the contact instructions in the code comments.

Some codes and device or specialty‑drug requests are managed through vendor programs (e.g., Carelon) for fully insured and vendor‑program eligible members. Where a code is managed by a vendor, the authorization pathway may differ; if the member is not eligible for the vendor program, Anthem will manage the authorization. Providers should follow the Responsible Party field in the code entry and the submission instructions.

The list distinguishes management responsibility between Carelon (vendor) and Anthem. Codes marked as managed by Carelon are processed by the vendor for fully insured and vendor‑program eligible members; Anthem manages authorization for members who are not vendor eligible or for specified categories (for example, transgender surgeries). Confirm the Responsible Party on each code entry and submit accordingly.

Within the excerpt there are no explicit clinical exclusions stated that universally remove services from consideration; rather, clinical determinations (including medical necessity or not‑medically‑necessary findings) are made by applying the referenced clinical guidelines and per‑code comments. Some codes (for example, specific unlisted bariatric procedures) are explicitly flagged as not medically necessary in certain specified circumstances.

Vendor management differs by setting: some procedures are managed by Carelon for outpatient/vendor‑eligible members and by Anthem for inpatient care or members not eligible for the vendor program. For codes with a Responsible Party designation, follow the code entry and submission pathway indicated in the list.

The document notes that even when a procedure is listed as requiring prior authorization, a medical necessity review may still occur at claims submission depending on the diagnosis, documentation, or reimbursement level. Providers should ensure that claim documentation is consistent with the previously authorized indication and the referenced guideline criteria.

Unlisted laparoscopy code 44238 is included with a specific comment when specified as a bariatric procedure identified as not medically necessary (e.g., SADI‑S). When reporting 44238 the submission must include the operative description and the guideline‑required preoperative documentation for bariatric procedures.

Several unlisted procedures are associated with non‑evidence‑based indications or emerging techniques (for example, some vaginal rejuvenation procedures, novel ablative techniques, or other cosmetic uses). These entries reference guideline review (ANC.00009, ANC.00007, SURG.00077) and may be denied or managed differently depending on evidence and guideline criteria.

Listed Procedure, HCPCS, Q/T/U Codes and Code Groups

Listed CPT and Unlisted CodesCPTCovered

00580	Anesthesia for heart transplant or heart/lung transplant
00796	Anesthesia for intraperitoneal procedures in upper abdomen; liver transplant (recipient)
15769	Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
15825	Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)
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
15835	Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock

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Craniofacial reconstruction codesCPTCovered

21184	Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra-and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining
21188	Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)

Facial grafts/augmentations/revisionsCPTCovered

21230	Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)
21235	Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)
21247	Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)
21255	Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)
21256	Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia)
21270	Malar augmentation, prosthetic material
21275	Secondary revision of orbitocraniofacial reconstruction

Pectus and spine unlisted codesCPTCovered

21740	Reconstructive repair of pectus excavatum or carinatum
21742	Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy
21743	Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with [thoracoscopy?]
22899	Unlisted procedure, spine [various specified uses]

Rhinoplasty, nasal and various unlisted surgical codesCPTCovered

22999	Unlisted procedure, abdomen, musculoskeletal system [when specified as repair of diastasis recti]
27599	Unlisted procedure, femur or knee [when specified as implantation of a medial knee implanted shock absorber or other specified implants]
28899	Unlisted procedure, foot or toes [when specified as cryoablation of plantar fasciitis or plantar fibroma]
29999	Unlisted procedure, arthroscopy [when specified as tendon repair using BioBrace implant or other specified uses]
30120	Excision or surgical planing of skin of nose for rhinophyma
30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
30410	Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or
30420	Rhinoplasty, primary; including major septal repair
30450	Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)

ENT, transplant, cardiac, vascular, and hematopoietic procedure codesmixedCovered

30999	Unlisted procedure, nose [various specified uses including nasal valve suspension, minimally invasive posterior nasal nerve treatment]
31299	Unlisted procedure, accessory sinuses [specified uses including sinus dilation systems]
31599	Unlisted procedure, Larynx (references WPATH Standards of Care)
32850	Donor pneumonectomy(s) (including cold preservation)
32851-32856	Various lung transplant procedures and backbench preparations
33140-33141	Transmyocardial laser revascularization codes
33225	Insertion of pacing electrode, cardiac venous system, for left ventricular pacing
33267-33269	Exclusion of left atrial appendage (open and thoracoscopic)
33340	Percutaneous transcatheter closure of the left atrial appendage with endocardial implant
33361-33370	Transcatheter aortic valve replacement and related procedures

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Unlisted cardiacCPT

33999

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]

Transplant / CAR-T related CPT codesCPTCovered

38204	Management of recipient hematopoietic progenitor cell donor search and cell acquisition
38205	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic
38206	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous
38207	Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage
38208	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor
38209	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor
38210	Transplant preparation of hematopoietic progenitor cells
38211	Transplant preparation of hematopoietic progenitor cells
38212	Transplant preparation of hematopoietic progenitor cells
38213	Transplant preparation of hematopoietic progenitor cells

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Unlisted palate/uvulaCPT

42299

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)]

Bariatric surgery and related codesCPTCovered

43632	Gastrectomy, partial, distal; with gastrojejunostomy (Billroth II) [when specified as bariatric surgery]
43633	Gastrectomy, partial, distal; with Roux-en-Y reconstruction [when specified as bariatric surgery]
43644	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
43645	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
43659	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]
43771	Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only
43775	Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)
43843	Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
43845	Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)
43846	Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy

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Intestinal donor/transplant codesCPTCovered

44132	Donor enterectomy (including cold preservation), open; from cadaver donor
44133	Donor enterectomy (including cold preservation), open; partial, from living donor
44135	Intestinal allotransplantation; from cadaver donor
44136	Intestinal allotransplantation; from living donor

Liver, pancreas, renal, transplant and urethroplasty codesmixedCovered

47370	Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency
47371	Laparoscopy, surgical, ablation of 1 or more liver tumor(s); cryosurgical
47380	Ablation, open, of 1 or more liver tumor(s); radiofrequency
47381	Ablation, open, of 1 or more liver tumor(s); cryosurgical
47382	Ablation, 1 or more liver tumor(s), percutaneous
47383	Ablation, 1 or more liver tumor(s), percutaneous
47384	Ablation, irreversible electroporation, liver, 1 or more tumors, including imaging guidance, percutaneous
47399	Unlisted procedure, liver
48550	Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation
48551	Backbench standard preparation of cadaver donor pancreas allograft

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Transplant-related CPT codesCPTCovered

50325	Preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary
50327	Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis
50328	Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis
50329	Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis
50340	Recipient nephrectomy (separate procedure)
50360	Renal allotransplantation, implantation of graft; without recipient nephrectomy
50365	Renal allotransplantation, implantation of graft; with recipient nephrectomy
50547	Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor

Genitourinary and male genital CPT codes (includes transgender-related)CPTCovered

53410	Urethroplasty, 1-stage reconstruction of male anterior urethra
53420	Urethroplasty, 2-stage reconstruction or repair of prostatic
53425	Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second stage
53430	Urethroplasty, reconstruction of female urethra
53448	Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session
53899	Unlisted procedure, urinary system [when specified as TULSA or portable normothermic organ perfusion system for kidney]
54125	Amputation of penis; complete
54440	Plastic operation of penis for injury
54520	Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach
54660	Insertion of testicular prosthesis (separate procedure)

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Female genital, gynecologic, and related CPT codes (includes many WPATH-referenced items)CPTCovered

56625	Vulvectomy simple; complete
56800	Plastic repair of introitus
56805	Clitoroplasty for intersex state
57110	Vaginectomy, complete removal of vaginal wall
57291	Construction of artificial vagina; without graft
57292	Construction of artificial vagina; with graft
57296	Revision (including removal) of prosthetic vaginal graft
57335	Vaginoplasty for intersex state
57426	Revision (including removal) of prosthetic vaginal graft
58140	Myomectomy, abdominal approach, 1-4 intramural myomas, total weight ≤250 g

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Neurosurgical, neurostimulation, and nerve procedure CPT codesCPTCovered

61630	Balloon angioplasty, intracranial, percutaneous
61635	Transcatheter placement of intravascular stent(s), intracranial
61736	LITT of lesion, intracranial; single
61737	LITT of lesion, intracranial; multiple
61850	Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical
61860	Craniectomy or craniotomy for implantation of neurostimulator electrodes
61863	Stereotactic implantation of neurostimulator electrode array in subcortical site without intraoperative microelectrode
61864	Each additional array (implantation)
61867	Stereotactic implantation with intraoperative microelectrode recording; first array
61868	Each additional array with intraoperative microelectrode recording

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Selected ENT/Facial/Transgender-related CPT and unlisted codesCPT

64864	Suture of facial nerve; extracranial.
64865	Suture of facial nerve; infratemporal, with or without grafting.
64866	Anastomosis; facial-spinal accessory.
64868	Anastomosis; facial-hypoglossal.
64999	Unlisted procedure — multiple specified implant/neuromodulation/neurosurgery uses referenced.
69090	Ear piercing.
69300	Otoplasty, protruding ear, with or without size reduction.
69399	Unlisted procedure, external ear (other specified).
69799	Unlisted procedure, middle ear (specified as implantation of hearing aids or balloon dilation of eustachian tube).
69949	Unlisted procedure, inner ear (specified uses).

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Biomarker testing prior auth policy exception (CA SB 535)

CA SB 535 biomarker testing exceptionNo prior authorization required for biomarker testing for members with advanced or metastatic stage 3 or 4 cancer; post-service medical necessity review for these tests is not permitted (only confirmation of stage permitted)

ScopeApplies to biomarker testing including cancer progression and recurrence testing for advanced/metastatic stage 3 or 4 cancer members

Provider actionVerify member’s cancer stage when submitting biomarker testing claims; do not perform post-service medical necessity denials for qualifying tests

ReferenceEffective July 1, 2022 California statute compliance (SB 535) — Anthem policy statement

Haller Index

DefinitionHaller Index — CT-derived index required or referenced for authorization of reconstructive pectus repair codes 21740, 21742, 21743

Required submissionHaller Index value and CT report must be submitted via Availity with prior authorization requests for pectus repair codes

Affected codes21740, 21742, 21743

BMI submission

Required elementSubmit patient BMI as part of bariatric surgery precertification documentation (examples: 43632, 43633, 43644, 43645, 43775, 43843)

Supporting docsNutritional consult, past participation in weight management program, pre- and post-op education and treatment plan, medical/mental clearance

Submission channelVia www.availity.com as specified in code comments

Uterus weight threshold

Uterus weight threshold250 g — used for code selection and guideline application for myomectomy and hysterectomy codes (eg, 58140, 58146, 58552, 58554, 58570–58574 variants)

Codes referencing threshold58140, 58146, 58150 series, 58260 series, 58541–58546, 58570–58574 (see code entries)

Provider actionInclude uterus weight (grams) in preauthorization documentation when applicable

remote interrogation monitoring period

Remote interrogation monitoring periodUp to 90 days for remote interrogation device evaluations (e.g., 0929T, 0948T, 0949T) per SURG.00153

Left atrial pressure monitoring windowUp to 30 days for left atrial pressure sensor data reporting and interpretation (e.g., 0934T) per SURG.00128

SubmissionRequests reference the named surgical guideline (SURG.00153 or SURG.00128) and require prior authorization

left atrial pressure monitoring data window

Left atrial pressure monitoring data windowUp to 30 days of daily uploads, interpretation and trend analysis for left atrial pressure sensor (code 0934T) per SURG.00128

Associated procedureTranscatheter implantation of wireless left atrial pressure sensor (0933T) with subsequent data window defined by 0934T

DocumentationPrior authorization required; follow SURG.00128 criteria and submit via Availity as instructed

BMI and weight management documentation example (C9785)

BMI and weight management documentation example (C9785)For endoscopic sleeve gastroplasty (C9785) submit BMI, nutritional consult, past participation in weight management program, pre-/post-op education and treatment plan, and medical/mental clearance via Availity

GuidelineC9785 references CG-SURG-83 for bariatric/endoscopic sleeve gastroplasty

Provider actionInclude specified preauthorization documents to align with CG-SURG-83 criteria

Weight capacity thresholds for mobility codes

Weight capacity thresholdsPower mobility codes specify patient weight capacity ranges (examples: pediatric K0890/K0891 up to 125 lb; K0813–K0816 up to 300 lb; K0824/K0826/K0827 301–600+ lb) — apply CG-DME-31

Provider actionDocument patient weight and select appropriate K-code matching capacity; include prosthetist evaluation via Availity when required

Reference guidelineCG-DME-31 governs prior authorization and clinical criteria for power wheelchairs

Wound surface area thresholds for skin substitute application

Wound surface area thresholds for skin substitutesSkin substitute application codes use thresholds: first 25 sq cm (or first 100 sq cm for larger sites), additional 25 sq cm or 100 sq cm increments; infants/children use 1% body area equivalence — per CG-SURG-127 and SURG.00011

Affected codes15271–15278 and 15150–15157 (tissue cultured autografts) — per code comments

Provider actionReport total wound surface area and apply correct incremental codes when requesting prior authorization

Fat graft injectate volume thresholds

Fat graft injectate volume thresholdsAutologous fat grafting codes use injectate volume increments: 25 cc and 50 cc (eg, 15771 = 50 cc or less; 15772 = each additional 50 cc; 15773 = 25 cc or less for face; 15774 = additional 25 cc)

Coding guidanceSelect primary code based on initial injectate volume and add incremental code(s) for additional volume as specified

DocumentationInclude volume injected and operative notes in prior authorization submission; reference CG-SURG-123 and WPATH when applicable

Skin substitute wound size threshold

Skin substitute wound size threshold100 sq cm (or 1% body area for infants/children) is used as a key threshold for code selection (first 100 sq cm vs additional 100 sq cm) for larger wound codes (15273–15278)

Smaller wound thresholdFirst 25 sq cm and additional 25 sq cm increments apply for smaller wound codes (15271–15272, 15275–15276)

Provider actionReport wound measurements (sq cm) and body area percentage for pediatric cases when requesting authorization

Autologous fat graft injectate increments

Autologous fat graft injectate incrementsCodes define increments of 25 cc (face/eyelids/orbits) and 50 cc (trunk/breast/limbs) for autologous fat grafting; use additional-code increments for volumes beyond base allowance

Example codes15771 (≤50 cc), 15772 (each additional 50 cc), 15773 (≤25 cc face), 15774 (each additional 25 cc face)

Submission requirementInclude injected volume details in prior authorization documentation and operative report

Uterus weight threshold for code assignment — 250 g (repeat)

Uterus weight threshold for code assignment250 g — used to determine appropriate hysterectomy/myomectomy code selection (uterus ≤250 g vs >250 g) and referenced across multiple hysterectomy/myomectomy codes

Affected codes58140, 58146, 58541–58546, 58570–58574, 58260 series (vaginal hysterectomy variants) — note code comments referencing 250 g

Provider actionDocument uterus weight (grams) in preauthorization request and operative reports when applicable

Precertification required for listed plastic/reconstructive codes

Precertification requirementPrior authorization (precertification) is required for the listed plastic and reconstructive CPT and unlisted codes; providers must submit required clinical documentation per the Criteria/Guideline referenced next to each code (eg, ANC.00008, ANC.00009, SURG.00023, CG-SURG-83, CG-DME-31).

Submission channelSubmit supporting documentation (photos, mental health letters, plastics evaluations, x-rays/tracings, BMI, wound measurements, prosthetist evals) via www.availity.com as directed in code comments

Contact pointsFor transplant/CAR-T and certain cellular therapies contact Anthem Transplant Unit (phone in comments) or follow TRANS.* guidance; Carelon manages reviews for fully insured/vendor-program eligible members where noted

Required Provider Submissions and Risk of Denial

Prior Authorization

Precertification required for listed plastic/reconstructive codes

These listed CPT and unlisted plastic/reconstructive procedure codes require precertification/prior authorization through Anthem Local PPO; providers must submit prior authorization requests per the Criteria/Guideline referenced for each code and use www.availity.com for required supporting documents when noted.

Obtain precertification/prior authorization before performing listed procedures.
Follow the specific Criteria/Guideline referenced next to each code (e.g., ANC.00008, ANC.00009, SURG.00023, CG-SURG-*).
Submit supporting documents via www.availity.com where comments specify.

Prior Authorization

Facial/orbital/craniofacial reconstruction codes — prior authorization & submission

Prior authorization is required for facial/orbital/craniofacial reconstruction codes (e.g., 21184, 21188); submit the supporting materials specified by the referenced guideline (ANC.00008 or CG-SURG-84) via Availity.

Submit photos via www.availity.com for ANC.00008-linked reviews.
For CG-SURG-84-linked codes submit x-rays and tracings via Availity as instructed.

Prior Authorization

Autograft and midface reconstruction codes — prior authorization & supporting docs

Prior authorization is required for autograft and midface reconstruction codes (e.g., 21230, 21235, 21247, 21255); submit photos or x-rays/tracings and other documentation via www.availity.com per the code comments and referenced criteria.

Upload photos via www.availity.com for ANC.00008-linked requests.
Submit x-rays and tracings for CG-SURG-84–referenced reconstructions as noted.

Prior Authorization

Orbit/augmentation/revision codes — prior authorization & documentation

Prior authorization required for orbit/augmentation/revision codes (e.g., 21256, 21270, 21275); for transgender-related cases submit photos and the mental health letter and plastics evaluation via Availity per the WPATH/ANC.00008 instructions.

Submit photos via www.availity.com for ANC.00008 reviews.
For transgender surgeries include a mental health letter and plastics evaluation via Availity.

Documentation Required

Pectus repair codes — include Haller Index/CT with prior auth

Prior authorization is required for reconstructive pectus repair codes (21740, 21742, 21743); include the Haller Index and, when applicable, the CT report submitted via www.availity.com per ANC.00009.

Include Haller Index +/- CT report with the prior authorization submission via Availity.
Follow ANC.00009 guidance referenced next to each pectus code.

Prior Authorization

Rhinoplasty and nasal procedure codes — prior authorization & photos

Prior authorization is required for rhinoplasty and related nasal procedure codes (e.g., 30120, 30400–30420, 30450); submit photos via Availity for ANC.00008 reviews and include mental health letter and plastics evaluation when the case is transgender-related.

Upload clinical photos via www.availity.com as indicated in code comments.
For transgender surgeries include mental health letter and plastics evaluation via Availity per WPATH guidance.

Prior Authorization

Other specialty and unlisted procedure codes — prior authorization

A range of specialty and unlisted procedure codes (ENT, cardiac, transplant, vascular, etc.) require prior authorization and reference specific clinical guidelines or transplant unit contact instructions; follow the per-code Criteria/Guideline and contact instructions.

Obtain prior authorization per the cited guideline on the code line.
If comments direct, contact the Anthem Transplant Unit (888-574-7215) for transplant/CAR-T related codes.

Prior Authorization

Transplant / CAR-T related codes — prior authorization & transplant unit contact

Prior authorization/precertification is required for transplant and CAR-T related CPT/Q/S codes; contact the Anthem Transplant Unit at 888-574-7215 when comments indicate and submit transplant guideline documentation as referenced.

Call Anthem Transplant Unit at 888-574-7215 for listed transplant/CAR-T codes.
Follow the TRANS.* or CC-* criteria referenced next to each code when requesting authorization.

Documentation Required

Bariatric surgery codes — prior authorization & pre-op documentation

Bariatric surgery and related procedure codes require prior authorization and are governed by CG-SURG-83; submit preoperative documentation including BMI, nutritional consult, history of participation in weight management, pre/post-op education and medical/mental clearance via Availity as specified.

Include BMI and nutritional consult documentation with the prior authorization request via www.availity.com.
Document prior participation in weight management program and required clearances per CG-SURG-83.

Prior Authorization

Precertification/Prior authorization required — assorted listed codes

These listed procedure codes require Anthem precertification/prior authorization; transplant-related entries often include additional contact instructions to the Anthem Transplant unit—follow the per-code comments and referenced guidelines.

Obtain prior authorization for codes marked as requiring precertification.
For transplant codes, follow contact instructions to Anthem Transplant unit when present.

Prior Authorization

Prior authorization required for listed codes — follow referenced guidelines

Prior authorization is required for the listed procedure and unlisted codes; submit prior authorization requests per the Criteria/Guideline referenced on each code and provide the documentation indicated in the code comments via Availity.

Use the Criteria/Guideline listed next to each code to determine documentation needs.
Upload photos, letters, or imaging via www.availity.com where comments direct.

Prior Authorization

Anthem prior authorization required — specified T/CPT codes

Anthem requires prior authorization/precertification for the CPT/T and related codes listed; follow the specified internal criteria/guidelines cited on each code when submitting requests.

Codes such as the listed T-codes require authorization per SURG.00153, SURG.00128, etc.
Consult the Criteria/Guideline referenced adjacent to each code for required materials.

Prior Authorization

Codes requiring prior authorization — follow referenced internal guidelines

The listed codes require prior authorization and are paired with Anthem internal criteria/guidelines (e.g., SURG.*, LAB.*); obtain precertification and submit documentation per the referenced policy.

Each U-code or T-code is associated with a specific LAB. or SURG. guideline—follow that guideline for documentation.
Submit requests via Availity when comments direct.

Prior Authorization

Prior authorization required for listed CPT/HCPCS/U codes

The listed CPT/HCPCS/U codes require precertification/prior authorization under Anthem Local PPO and are governed by the referenced clinical guideline(s); providers must submit requests and supporting documentation per those guidelines.

Check the Criteria/Guideline ID listed with each code to determine required supporting materials.
Submit prosthetist evaluations, prescriptions, photos, or letters via www.availity.com when specified.

Prior Authorization

Codes requiring prior authorization — HCPCS/CPT/J/K entries

These HCPCS/CPT/J/K codes are on the Anthem Local PPO precertification/prior authorization list and require prior authorization per the Criteria/Guideline referenced for each code.

Obtain prior authorization per the listed Criteria/Guideline (e.g., CG-DME-31 for many K-codes).
Follow any submission instructions provided in the code comments.

Prior Authorization

Prior authorization required — K/L/Q code groups

The listed K- and selected L- and Q-codes require precertification/prior authorization under Anthem and reference internal criteria (for example, CG-DME-31 for power mobility devices); submit required documentation as noted.

For power mobility (K-codes) follow CG-DME-31 and submit prosthetist evaluation and MD prescription via Availity when directed.
For L- and Q-codes follow the Criteria/Guideline cited next to each code.

Prior Authorization

Graft/allograft Q-codes — prior authorization per SURG.00011

Amniotic membrane and related graft product Q-codes require prior authorization and are governed by SURG.00011; obtain precertification and bill per square centimeter as indicated.

Request prior authorization per SURG.00011 for listed Q-codes.
Charge and document per-square-centimeter units as shown on code entries.

Documentation Required

Breast reconstruction / transgender surgery — submit mental health letter & plastics eval

Selected breast reconstruction S-codes (e.g., S2066–S2068) reference SURG.00023 and WPATH Standards of Care; for transgender surgeries submit a mental health letter and a plastics evaluation via www.availity.com as specified.

Include mental health letter and plastics evaluation for transgender-related breast reconstruction submissions via Availity.
Follow SURG.00023 clinical criteria referenced next to the S-code.

Prior Authorization

Skin substitute / tissue cultured graft codes — prior authorization

Tissue-cultured skin autograft and skin substitute application CPT codes require precertification/authorization and reference CG-SURG-127 and SURG.00011; management may be by Carelon for fully insured/vendor-program members.

Obtain authorization per CG-SURG-127 and SURG.00011 for codes like 15150–15278.
Carelon may manage authorization for eligible members; otherwise Anthem manages the review.

Prior Authorization

Autologous fat grafting — prior authorization & WPATH-linked documentation

Autologous fat grafting CPT codes (e.g., 15771–15774) require prior review and reference CG-SURG-123; for transgender surgeries follow WPATH-linked requirements and include mental health letter and plastics evaluation as indicated.

Submit prior authorization per CG-SURG-123 for autologous fat grafting codes.
For transgender-related procedures include WPATH-aligned documentation via Availity.

Documentation Required

Micropigmentation / adjacent tissue transfer — prior authorization & documentation

Tattooing/micropigmentation and certain adjacent tissue transfer procedures require review and reference ANC.00007, SURG.00023, SURG.00096 and WPATH Standards of Care; submit photos and any required letters via Availity per code comments.

Submit photos for ANC.00007 reviews via www.availity.com.
For transgender surgeries include mental health letter and plastics evaluation as specified.

Prior Authorization

Precertification required for listed plastic surgery codes — manage per responsible party

Precertification is required for the listed plastic surgery CPT codes; management may be assigned to Carelon for fully insured/vendor-program-eligible members and to Anthem for members not eligible for vendor programs—follow the per-code assignment and referenced guideline when submitting requests.

Verify whether Carelon or Anthem is the responsible prior authorization manager for the member.
Submit required documentation via Availity when code comments instruct.

Prior Authorization

Precertification required for listed reconstructive and related codes

Additional reconstructive and related CPT codes require prior authorization and reference specific clinical criteria/guidelines (e.g., CG-SURG-71, CG-SURG-99, CG-SURG-84, SURG.00129); submit the documentation specified by the cited guideline when requesting authorization.

Provide imaging, studies or other materials required by the referenced guideline (for example, sleep study or x-rays/tracings).
Confirm management assignment (Carelon vs Anthem) as noted for the code.

Prior Authorization

Prior authorization required for listed procedure codes — submit required studies

These CPT procedure codes are listed on the Anthem Local PPO precertification/prior authorization list and require prior authorization review; follow the Criteria/Guideline cited and upload required documentation via Availity as directed.

For SURG.00129-related procedures include a sleep study when required.
For CG-SURG-84-related procedures include x-rays and tracings as specified.

Prior Authorization

Prior authorization required — codes with responsible party and guideline

These CPT codes are on the Anthem Local PPO Precertification/Prior Authorization List and require prior authorization; each code is assigned a Responsible Party (Anthem or Carelon) and an associated Criteria/Guideline that must be followed when submitting a request.

Do not submit claims for these codes without first obtaining required precertification when Responsible Party = Anthem.
If code comments indicate Carelon management, verify member eligibility and submit to the correct vendor if applicable.

Prior Authorization

Precertification required for listed codes — Carelon vs Anthem management

These listed CPT codes require precertification/prior authorization; for fully insured and vendor-program-eligible members management responsibility may be assigned to Carelon—verify member program eligibility and submit to the appropriate reviewer.

Verify whether the member’s plan is managed by Carelon for outpatient/vendor program handling.
If not eligible for vendor program, submit prior authorization to Anthem per the code comments.

Documentation Required

Required supporting documents for reviews — photos, MH letters, plastics evals

Providers must submit required supporting documents for many listed procedure reviews (especially transgender-related surgeries and ANC.00008/ANC.00009 items) — common items include clinical photos, mental health letters, and plastics evaluations submitted via www.availity.com.

Upload clinical photos to www.availity.com when code comments direct (ANC.00008/ANC.00009/ANC.00007).
For transgender surgeries submit mental health letter(s) and a plastics evaluation via Availity as specified.

Documentation Required

Photos and mental health/plastics evaluation — submit via Availity for ANC.00008/WPATH-linked codes

For codes associated with ANC.00008 and WPATH Standards of Care (and many transgender-related procedures), submit photos via www.availity.com; for transgender surgeries also submit the required mental health letter and plastics evaluation per the code comments.

Photos must be uploaded via Availity when ANC.00008/ANC.00009 comments require them.
Transgender surgery submissions must include the mental health letter and plastics evaluation via Availity as noted.

Documentation Required

Imaging requirement (Pectus) — submit Haller Index and CT report via Availity

For reconstructive pectus repair codes (21740, 21742, 21743) include the Haller Index and the CT report (when applicable) with the prior authorization submission via www.availity.com per ANC.00009.

Provide numeric Haller Index and attach CT report to support medical necessity.
Submit these documents through the Availity portal as instructed.

Documentation Required

Bariatric pre-op documentation — BMI, nutrition, weight-management history

For bariatric procedure prior authorization (CG-SURG-83) include BMI, nutritional consultation, documentation of past participation in a weight management program, pre- and post-op education and treatment plan, and medical/mental clearance submitted via www.availity.com as specified.

Include BMI and documented weight-management participation history.
Attach nutritional consult notes and pre/post-op education materials via Availity.

Billing Rule

Transplant unit contact — call 888-574-7215 and submit TRANS.* documentation

For transplant- and cell-therapy-related codes, contact the Anthem Transplant Unit at 888-574-7215 as directed in code comments and submit the transplant guideline documentation referenced (TRANS.*) when requesting prior authorization.

Call Anthem Transplant Unit at 888-574-7215 for transplant/CAR-T authorization guidance.
Provide the TRANS.*–referenced documentation when submitting the authorization request.

Documentation Required

Sleep study submission — include sleep study for palatal/sleep-related procedures

For palatal/sleep-related procedures (e.g., 42299 and SURG.00129-linked codes) include and submit the relevant sleep study via www.availity.com as part of the prior authorization request.

Attach the diagnostic sleep study report via Availity when SURG.00129 is referenced.
Omission of the sleep study may affect authorization decisions.

Documentation Required

Photos and mental health letters via Availity — for transgender surgeries and ANC.00009 items

For transgender surgeries and ANC.00009 items providers must submit photos and the required mental health letters via www.availity.com as indicated in code comments (some codes require two mental health letters).

Submit two mental health letters via Availity where the code comments require two letters.
Upload clinical photos via Availity when requested for ANC.00008/ANC.00009 reviews.

Documentation Required

Required submission materials for ANC.00008 / WPATH — photos, MH letter, plastics eval

For services subject to ANC.00008 and WPATH Standards of Care (e.g., facial nerve repairs and many transgender-related procedures), submit photos via www.availity.com and, for transgender surgeries, include the mental health letter and a plastics evaluation per the code comments.

Upload photos for ANC.00008 reviews via Availity.
Include mental health letter and plastics evaluation for transgender surgeries via Availity.

Documentation Required

Additional documentation for complex surgical/transplant codes — contact/unit & pre-op materials

For complex surgical or transplant-related codes (e.g., CG-SURG-28, MED.00151, TRANS.00004, TRANS.00035) follow the code comments: contact the Anthem Transplant Unit when directed or submit detailed preoperative documentation (BMI, psych evaluation, nutritional consult, 6-month weight management history, pre/post-op education and clearance) via Availity.

Contact Anthem Transplant Unit when code comments indicate TRANS.* involvement.
Provide the expanded pre-op documentation via Availity as noted in the comments.

Documentation Required

Documentation must follow the referenced internal guideline

Each listed code includes a Criteria/Guideline reference (for example, SURG.00153 for many T-codes or LAB.00011 for U-codes) that must be followed when submitting a prior authorization request; providers should consult the named guideline to determine required documentation.

Reference the Criteria/Guideline ID listed next to the code to locate the specific policy.
Provide documentation required by that guideline when requesting authorization.

Documentation Required

Required preauthorization documentation (example: C9785)

For procedures like endoscopic sleeve gastroplasty (C9785) submit BMI, nutritional consult, history of participation in a weight management program, pre- and post-op education and treatment plan, and medical/mental clearance via www.availity.com as part of preauthorization.

Include BMI and weight-management participation documentation.
Attach nutrition consult and pre/post-op education materials via Availity.

Billing Rule

Unclassified drug/specialty therapy handling — contact transplant unit / specialty routing

When unclassified drug codes (J3490, J3590) are used for gene therapies or other specialty biologics, contact the Anthem Transplant Unit at 888-574-7215 for guidance and follow the MED.* / TRANS.* references; specialty pharmacy routing may apply.

Call Anthem Transplant Unit at 888-574-7215 for gene therapy/specialty biologic prior authorization guidance.
If codes are used for specialty pharmacy products, follow Carelon/CarelonRx routing instructions where indicated.

Documentation Required

Required documentation via Availity for prosthetics/orthotics

Submit prosthetist evaluation, MD prescription and dollar amount via www.availity.com for specified prosthetic/orthotic codes (e.g., K1007, L2999, L8701, L8702) and include photos where the code comments require them.

Upload prosthetist evaluation and MD prescription with pricing via Availity for K/L codes as instructed.
Attach photos for items like L8045 when required.

Prior Authorization

Contact/transplant unit instructions — CAR-T and cellular therapy Q-codes

For CAR-T and other cellular therapy Q-codes, contact the Anthem Transplant Unit (phone number provided in comments) and follow the referenced CC-* or TRANS.* criteria when requesting prior authorization.

Contact Anthem Transplant Unit at 888-574-7215 for CAR-T prior authorization processing.
Provide documentation required by CC-0150/CC-0151 or other CC-* criteria as referenced.

Documentation Required

Transgender surgery documentation — mental health letter and plastics evaluation required

For transgender surgeries providers must submit a mental health letter and a plastics evaluation via www.availity.com (or per the directions in the code comments) to allow review under WPATH-linked pathways.

Include required mental health letter(s) and plastics evaluation with the prior authorization submission via Availity.
Some transgender surgery code comments specify two mental health letters—follow the code-specific instruction.

Billing Rule

Transplant documentation/contact — call Anthem Transplant Unit

For transplant-related procedures and cellular therapies, contact the Anthem Transplant Unit at 888-574-7215 as noted in code comments when submitting prior authorization requests.

Call 888-574-7215 to coordinate transplant or cellular therapy authorizations.
Provide the TRANS.*–referenced documentation during the authorization process.

Documentation Required

Required supporting documentation — photos, visual fields, x-rays/tracings

Submit photos for ANC.00007/ANC.00009/ANC.00008 reviews; for blepharoplasty include visual fields, and for maxillofacial/orthognathic (CG-SURG-84) submit x-rays and tracings as specified in code comments via Availity.

Upload photos and visual field testing for blepharoplasty (15820–15823) where requested.
Submit x-rays and tracings for CG-SURG-84–linked orthognathic codes via Availity.

Documentation Required

Required documentation for specific guideline reviews — sleep study, imaging, WPATH materials

For Anthem reviews tied to SURG.00129 submit a sleep study; for CG-SURG-84 submit x-rays and tracings; for transgender surgeries submit mental health letters and a plastics evaluation via www.availity.com per the code comments.

Attach sleep study reports when SURG.00129 is referenced.
Provide x-rays/tracings for CG-SURG-84 and WPATH-aligned documentation for transgender surgeries.

Note

Documentation must follow the referenced internal guideline

Each listed code includes a Criteria/Guideline reference indicating the internal policy that governs prior authorization decisions; providers must follow that referenced guideline to determine required documentation and medical necessity logic.

Consult the named Criteria/Guideline (e.g., SURG.*, CG-SURG-*, LAB.*) for per-code medical necessity requirements.
Submit the documentation specified by the referenced guideline with the prior authorization request.

Documentation Required

Bariatric and endoscopic bariatric submission requirements — BMI and weight-management documentation

Provide BMI, nutritional consult, history of participation in weight management, pre/post-op education and treatment plan, and medical/mental clearance for certain bariatric or endoscopic bariatric procedures (e.g., C9785 and other CG-SURG-83 items) when submitting prior authorization via Availity.

Include BMI and documented evidence of weight-management program participation.
Attach nutrition consult notes and pre/post-op education materials.

Documentation Required

Photos and 2 mental health letters required for ANC.00009 / transgender surgeries

For ANC.00009–associated procedures and transgender surgeries, photos may be requested and two mental health letters are required for Anthem review; submit these materials via www.availity.com as specified in code comments.

Submit two mental health letters via Availity where code comments require them.
Upload photos for ANC.00009 reviews when requested.

Documentation Required

Required documentation for ANC.00009 and transgender surgeries — photos and two MH letters

For ANC.00009 and transgender surgery reviews, photos may be requested and must be submitted via www.availity.com; transgender surgeries require two mental health letters submitted via Availity when specified.

Upload requested clinical photos via Availity for ANC.00009 reviews.
Where required, include two mental health letters for transgender surgery review.

Documentation Required

Sleep study submission for SURG.00129 and related device reviews

For sleep disorder management and SURG.00129–related device reviews, submit the diagnostic sleep study via www.availity.com as part of the prior authorization package when requested.

Attach sleep study reports via Availity for SURG.00129-linked authorizations.
Omission of the sleep study may delay or affect authorization decisions.

Denial Risk

Verification and precertification risk — confirm benefits and obtain precert

Follow the referenced Criteria/Guideline for each listed code when preparing documentation; failure to verify member benefits or to obtain required precertification may result in medical necessity review or claim denial.

Verify member benefits and eligibility prior to scheduling services.
Obtain required precertification; absence of precertification may result in denial.

Denial Risk

Missing required Haller Index/CT may cause denial — pectus repair codes

Submissions for reconstructive pectus repair (21740, 21742, 21743) must include the Haller Index and CT report when required; omission of these imaging items may lead to denial of the request.

Include Haller Index and CT report in the prior authorization submission via Availity.
Missing Haller Index/CT may result in denial.

Denial Risk

Missing supporting documentation — risk of denial or delay

Failure to submit required supporting materials (e.g., photos, mental health letter, plastics evaluation, x-rays/tracings) via www.availity.com for codes tied to ANC.00008, CG-SURG-84, WPATH Standards of Care or other referenced guidelines may result in denial or delay.

Upload all documentation specified in the code comments via Availity.
Lack of required documentation may trigger denial or require additional review time.

Denial Risk

Prior authorization required for Anthem-responsible codes — risk of denial if not obtained

Do not submit claims for Anthem-responsible codes without first obtaining required precertification/prior authorization; submitting without prior authorization may result in claim denial when the code’s Responsible Party = Anthem.

Check the Responsible Party assignment and obtain authorization from Anthem when indicated.
Claims submitted without required precertification for Anthem-managed codes may be denied.

Prior Authorization

Preauthorization required for listed procedural (T) codes — obtain per SURG.*

Requests for the listed procedural T-codes (e.g., 0924T–0934T) are subject to Anthem prior authorization per the referenced internal criteria (e.g., SURG.00153); lack of prior authorization may trigger claim denial or precertification denial.

Obtain authorization per the SURG.* guideline referenced for T-codes.
Submit any required supporting documentation indicated by the guideline.

Prior Authorization

Preauthorization required for listed laboratory (U) codes — follow LAB.* guidance

Proprietary laboratory/diagnostic U-codes (e.g., 0052U–0108U and others) require precertification/prior authorization per their associated laboratory policies (e.g., LAB.00011, LAB.00031, LAB.00036); follow the LAB.* guidance when submitting requests.

Refer to the LAB.* guideline referenced next to each U-code to determine required documentation.
Submit prior authorization requests for U-codes to Anthem as indicated.

Documentation Required

Documentation requirement may affect authorization — implantable breast prosthesis and WPATH

Certain implantable breast prosthesis entries (C1789 / L8600) reference WPATH Standards of Care and may require submission of a mental health letter and plastics evaluation via www.availity.com; absence of these documents can affect authorization.

Submit mental health letter and plastics evaluation for implantable breast prosthesis when the code comments reference WPATH.
Failure to provide required documentation may prevent authorization under the referenced guideline.

Billing Rule

Transplant/specialty drug contact requirement — contact Anthem Transplant Unit when indicated

Some injectable therapies and transplant-related products require contacting the Anthem Transplant Unit (per code comments) for authorization guidance; failure to contact the transplant unit may delay or prevent authorization.

Contact Anthem Transplant Unit at 888-574-7215 when code comments instruct.
Provide any transplant-specific documentation required by TRANS.* criteria.

Billing Rule

Submission requirements for selected L/K codes — prosthetist evaluation and MD prescription

Failure to submit prosthetist evaluation, MD prescription and dollar amount via www.availity.com for listed prosthetic/orthotic L/K codes (e.g., K1007, L2999, L8701/L8702) may result in denial or the need for additional review.

Upload prosthetist evaluation, MD prescription and pricing information via Availity as instructed.
Missing these items may cause claim denial or authorization delays.

Denial Risk

Missing transgender documentation — mental health letters/plastics eval required

Failure to submit required mental health letters and plastics evaluation for transgender-related procedures (per WPATH/ANC.00008/ANC.00009 code comments) may prevent proper review or result in denial.

Include required mental health documentation and plastics evaluation via Availity for transgender surgeries.
Omitting required materials may prevent processing under the WPATH-linked review pathway.

Denial Risk

Transplant unit contact required — call 888-574-7215 or risk delay/denial

Not contacting the Anthem Transplant Unit for listed transplant codes (e.g., S2053–S2150 series, 32850–32856, 33929–33945, etc.) when comments instruct may delay or prevent authorization; call 888-574-7215 as shown in the code comments.

Phone Anthem Transplant Unit at 888-574-7215 for transplant-related prior authorization coordination.
Follow TRANS.* guidance and supply requested transplant documentation.

Documentation Required

Documentation triggers for blepharoplasty — photos and visual fields required

Failure to submit required photos and visual fields for blepharoplasty codes (15820–15823) may trigger non-approval or transfer of management to Anthem; upload photos and visual field testing via Availity as indicated.

Attach clinical photos and visual field test results via www.availity.com for blepharoplasty reviews.
Missing these items can lead to non-approval or additional review.

Denial Risk

Transgender surgery submission risk — missing MH letter/plastics eval prevents WPATH review

Omission of required mental health letters and plastics evaluation for transgender surgery reviews will prevent processing under the WPATH-linked criteria and may result in delays or denial; submit these documents via Availity as specified.

Submit the mental health letter(s) and plastics evaluation via www.availity.com when required by code comments.
Failure to include these documents will prevent review under WPATH-aligned pathways.

Documentation Required

Sleep study requirement — include sleep study for SURG.00129-linked procedures

For SURG.00129-related orthognathic or sleep-related procedures, include the required sleep study with the prior authorization; omission of a sleep study may affect authorization decisions.

Attach sleep study via www.availity.com when SURG.00129 is referenced.
Missing sleep study data can lead to denial or need for additional review.

Denial Risk

Missing required documentation may lead to denial — provide guideline-specified materials

Failure to submit required supporting documentation (e.g., sleep study for SURG.00129; x-rays and tracings for CG-SURG-84; mental health letter and plastics evaluation for transgender surgeries) when requesting Anthem review may trigger denial or require additional review.

Ensure all guideline-specified documents accompany the prior authorization request via Availity.
Incomplete submissions may be denied or routed for supplemental review.

Note

Definitions, Contacts, and Reference Guidelines

WPATH Standards of Care

WPATH referenceWPATH Standards of Care (World Professional Association for Transgender Health) are cited as the standard for many transgender-related procedure authorizations; providers directed to https://wpath.org

Documentation requirementsWPATH-linked entries commonly require mental health letters and plastics evaluation submissions via Availity

Codes using WPATHMultiple CPT and HCPCS codes across genital, breast, facial and reconstructive groups reference WPATH in comments

WPATH Standards of Care (repeat reference)

WPATH cited for transgender proceduresWPATH Standards of Care referenced repeatedly for authorization of facial, craniofacial, and gender-affirming surgeries; mental health letters and plastics evaluations are required per comments

Provider instructionSubmit photos and required mental health/plastics documentation via www.availity.com when codes reference WPATH

Associated guidelinesMany codes referencing WPATH also list ANC.00008 or CG-SURG-84 as the clinical guideline for review

Haller Index — CT-derived index required for pectus repair authorization

Haller Index requirementHaller Index is a CT-derived index required/ referenced for authorization of reconstructive pectus repair codes (21740, 21742, 21743)

Submission methodProvide Haller Index with CT report via www.availity.com as specified in code comments (ANC.00009)

ConsequenceMissing Haller Index/CT may result in denial of authorization

WPATH reference for urethroplasty procedures

WPATH for urethroplasty/urethral proceduresWPATH Standards of Care are cited as the clinical guideline for urethroplasty procedures related to gender-affirming surgery

Provider actionFollow WPATH standards and submit mental health letters and plastics evaluations via Availity when indicated

Reference linkhttps://wpath.org

WPATH Standards of Care — provider direction and documentation

WPATH submission directionProviders are directed to https://wpath.org and to submit required mental health documentation (eg, 2 letters where specified) and plastics evaluations via www.availity.com for WPATH‑linked procedures

Typical requirementsPhotos, mental health letters, plastics evaluation, and other supporting documentation as specified by code comments

Where appliedMultiple gender-affirming and related reconstructive procedure entries

Anthem Transplant unit — contact info and role

Anthem Transplant Unit contactContact Anthem Transplant Unit at 888-574-7215 for transplant-related authorizations and queries

When to contactCodes with TRANS.* or CC-* criteria references (eg, donor/recipient transplant codes, CAR-T and cellular therapy Q-codes)

ActionCall transplant unit and submit required TRANS guideline documentation per comments

Responsible Party = Anthem

Responsible Party = AnthemIndicates Anthem is the payer contact for prior authorization decisions for the specified code entries

ImplicationProviders must request authorization from Anthem (not vendor) for listed Anthem-responsible codes

ExamplesMany procedural, transplant, and specialty codes in this list have Responsible Party = Anthem noted in comments

Phone instruction for transplant-related code prior authorization

Transplant unit phone instructionWhen comments indicate, contact the Anthem Transplant unit at 888-574-7215 for prior authorization routing and guidance

Codes citing this instructionExamples include 32850 series, 50325–50329, 50547, many Q-/S-codes and J-code gene therapies

Follow-upProvide transplant-specific documentation per referenced TRANS.* guidelines

Proprietary laboratory (U) codes

Proprietary laboratory (U) codesU-codes (eg, 0052U–0108U and many others) denote proprietary algorithmic laboratory tests that require Anthem laboratory policy review (LAB.* references)

ActionSubmit prior authorization per the LAB.* criteria referenced next to each U-code

Examples0052U, 0080U, 0108U, 0342U, etc., all list Responsible Party = Anthem and LAB.x references

Category III / T codes

Category III / T codesT-codes (eg, 0924T–0934T) represent new/technology procedural services that are subject to Anthem prior authorization and linked to SURG.* guidelines

Provider actionObtain prior authorization per the referenced SURG.* criteria when submitting T-code requests

Examples0924T–0934T entries reference SURG.00153, SURG.00128 and related criteria

WPATH Standards of Care — reference for C1789 authorization

WPATH for C1789/breast prosthesisWPATH Standards of Care cited as reference for implantable breast prosthesis (C1789) authorization and associated mental health documentation

Provider actionSubmit mental health letter and plastics evaluation via Availity when C1789 references WPATH in comments

Referencehttps://wpath.org per code comments

CG-DME-31 — Anthem guideline for power wheelchairs and DME

CG-DME-31 referenceCG-DME-31 is the Anthem guideline referenced for power wheelchairs and DME prior authorization criteria

ActionFollow CG-DME-31 documentation and capacity criteria when requesting prior authorization for K-codes

ExamplesK0010–K0014, K0800–K0891 and many related K-codes reference CG-DME-31

MED.00135 / MED.00142 / MED.00120 / TRANS.00010 — policy references

Specialty/transplant policy referencesMED.00135, MED.00142, MED.00120, TRANS.00010 and related specialty/transplant policies are cited for gene therapies and transplant-related codes; contact Transplant Unit when indicated

ActionFollow the named MED./TRANS. policy criteria and contact the Anthem Transplant Unit for required coordination

ExamplesJ1411, J1412, J3398–J3399 and many other J-codes reference MED.* or TRANS.* policies

Availity submission — provider portal for required documentation

Availity submission portalwww.availity.com is the provider portal to submit photos, mental health letters, prosthetist evaluations, MD prescriptions, dollar amounts and other required documentation for prior authorization

When usedRequired for ANC.00008/WPATH submissions, prosthetic/orthotic documentation (eg, K1007, L2999), bariatric pre-op materials, and other code-specific requests

Provider actionUpload requested materials to Availity as part of the authorization request to avoid delays

CG-DME-31 — repeated reference for DME criteria

CG-DME-31 repeatedCG-DME-31 is reiterated as the governing guideline for power wheelchair coverage and prior authorization

ImplicationProviders must reference CG-DME-31 when submitting prior authorization for mobility/DME K-codes

Submission noteInclude weight capacity and prosthetist evaluation per Availity when indicated

SURG.00011 — surgical criteria for amniotic membrane/allografts

SURG.00011 referenceSURG.00011 is the Anthem surgical guideline referenced for amniotic membrane and related allograft product Q-codes

ActionPrior authorization for Q-codes requires adherence to SURG.00011 and per-square-centimeter billing as noted in code entries

ExamplesQ4305–Q4345 series reference SURG.00011 in comments

WPATH Standards of Care — referenced for transgender-related procedures

WPATH for transgender reviewsWPATH Standards of Care is the clinical standard for transgender-related surgical reviews; mental health letters and plastics evaluations are required per code comments

Provider instructionSubmit 1–2 mental health letters and plastics evaluation via Availity as specified by code comments and referenced ANC/ANC.00009 guidelines

Reference linkhttps://wpath.org

Carelon — vendor managing reviews where indicated

Carelon vendor roleCarelon manages reviews for fully insured and vendor-program-eligible members for specified procedure codes; Anthem manages reviews for members not eligible for vendor programs

Implication for providersVerify member plan and vendor assignment; some codes will be routed to Carelon vs Anthem as noted in code comments

ExamplesMany skin substitute, reconstructive, and DME codes are managed by Carelon for eligible members

WPATH Standards of Care — guidance for transgender-related coding and review

WPATH guidance for coding/reviewWPATH Standards of Care are repeatedly referenced as the framework for transgender-related coding and review; documentation requirements are specified in code comments

Effect on authorizationTransgender surgeries often require submission of two mental health letters and plastics evaluations via Availity as part of authorization under WPATH-linked criteria

Provider actionFollow WPATH and the code-specific comments when preparing prior authorization packages

WPATH Standards of Care — clinical framework reference

WPATH as clinical frameworkWPATH Standards of Care cited as the clinical framework for transgender surgeries and related breast reconstruction procedures; documentation and submission requirements reference WPATH

Associated codesMultiple facial/orthognathic and genital/breast reconstruction codes reference WPATH alongside CG-SURG-84 or SURG.00023

Submission noteSubmit x-rays/tracings for CG-SURG-84, sleep study for SURG.00129, and WPATH documentation for transgender cases via Availity

Transgender surgeries — WPATH-linked documentation requirement

Transgender surgeries documentation standardTransgender surgeries require submission of two mental health letters (where specified) and adherence to WPATH Standards of Care; photos may also be requested via Availity

Submission channelSubmit required letters and photos via www.availity.com per code comments

Codes affectedMultiple ANC.00009 and WPATH-referenced CPT/HCPCS codes (see code list) require these materials

Policy Background and Scope

This document is an administrative precertification/prior authorization list identifying plastic and reconstructive surgery CPT and unlisted codes that require pre‑service review. Many entries reference Anthem clinical guidelines and the WPATH Standards of Care for transgender‑related surgeries, and specify the supporting documentation (photos, mental health letters, Haller Index/CT, sleep study, BMI/nutritional consult, etc.) that must accompany a prior authorization request.

Policy Revision History

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyAnthem Local PPO Precertification/Prior Authorization List — Plastic/Reconstructive Surgery codes

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

SourceLink

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Anthem Local PPO Precertification/Prior Authorization List — Plastic/Reconstructive Surgery codes

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Coverage Criteria and Prior Authorization Rules

Prior Authorization with guideline-linked medical necessity

Covered when prior authorization is obtained per Anthem clinical guidelines referenced for each code

Follow submission via Availity or contact specific units (e.g., Transplant Unit) when indicated

Authorization linked to external criteria/guidelines

Prior authorization required when procedures reference specific Anthem criteria or external standards

See ANC.00008 and WPATH Standards of Care for full medical necessity criteria

Submission requirements for CG-SURG-84: For codes that reference CG-SURG-84, submit x-rays and tracings via www.availity.com as part of the authorization request.

See CG-SURG-84 for detailed criteria

Exact numeric threshold is in ANC.00009 guideline

Transplant and cell therapy authorization criteria

Covered when services meet the referenced Anthem criteria/guidelines and prior authorization requirements

See TRANS.* and CC-* guideline documents for medical necessity criteria

Bariatric surgery coverage criteria

Covered when ALL of the following are met per CG-SURG-83

Exact numeric BMI thresholds are specified within CG-SURG-83, not in this excerpt

Gender-affirming surgery criteria

Covered when services meet WPATH Standards of Care referenced standards

Gender-affirming urethroplasty: Urethroplasty codes reference WPATH Standards of Care for criteria and are subject to those standards for coverage

Providers should follow WPATH guidance; link provided in comments

Covered with guideline-based prior authorization

These codes are subject to precertification and to referenced Anthem clinical guidelines or external standards:

Transplant codes: Codes such as 50325, 50327, 50328, 50329, 50340, 50360, 50365, 50547 require contacting Anthem Transplant unit and follow TRANS.* guidelines

Contact 888-574-7215; see TRANS.00011 / TRANS.00039 / TRANS.00038 as referenced

See https://wpath.org; specific submission instructions appear in code comments

Providers must follow the specified guideline(s) referenced next to each code

General Prior Authorization Requirement

Codes are subject to authorization when they meet the referenced Anthem internal guidance

Specific inclusion/exclusion criteria are contained in the referenced internal guidelines

Power wheelchair / DME Prior Authorization

Covered when prior authorization per Anthem criteria is obtained:

See documentation module for Availity submission requirements

Amniotic membrane / allografts

Covered when prior authorization per SURG.00011 is obtained:

Amniotic/allograft prior auth: Providers must obtain prior authorization for listed Q-codes per SURG.00011; per-code per-square-centimeter billing applies.

Follow SURG.00011 criteria and submit required documentation via Availity if requested

Orthotics / Prosthetics Prior Authorization

Covered when documentation and prior authorization requirements are met:

Transgender surgery references require WPATH documentation where indicated

Cellular therapy prior authorization

Covered when Anthem clinical criteria and transplant unit coordination are followed:

Cellular therapy prior auth: For listed Q-codes (CAR-T products), contact Anthem Transplant Unit and follow the referenced CC-xxxx criteria for authorization; phone contact provided in comments.

See comments for contact number

Breast reconstruction / WPATH-linked requirements

Covered when surgical criteria and WPATH documentation are met:

Also provides WPATH link in comments

Code review / management

Covered when reviewed per the referenced Anthem/Carelon guideline(s) and documentation requirements

Management may be by Carelon for fully insured/vendor eligible members; transgender surgeries require WPATH documentation.

Coverage mapping to referenced clinical guidelines

Codes are subject to medical necessity review according to the referenced criteria/guidelines and may require specified documentation

See referenced guideline for detailed medical necessity criteria.

ANC.00007-related cosmetic/aesthetic procedures: Procedures referencing ANC.00007 generally require photos for review; coverage determined per ANC.00007 criteria.

See ANC.00007 for specific cosmetic vs reconstructive determinations.

SURG.00129 orthognathic/airway procedures: SURG.00129-related codes may require sleep study results and x-rays/tracings; authorization per SURG.00129 and CG-SURG-84.

Submit sleep study and imaging as specified.

General prior authorization criteria

Prior authorization and supporting documentation required

Management may be by Carelon for fully insured/vendor-program-eligible members or by Anthem for members not eligible for vendor programs.

Authorization management and guideline requirements

Covered when prior authorization is obtained per responsible party and referenced guideline

See individual code comments for specifics (WPATH Standards, CG/MCG guidelines).

Guideline linkage: Specific codes reference criteria/guidelines (e.g., WPATH Standards of Care, CG-SURG-12, CG-MED-81, SURG.00077, CG-SURG-79, SURG.00142, etc.) which must be met for approval.

Provider must follow the named guideline for clinical criteria.

Listed Procedure, HCPCS, Q/T/U Codes and Code Groups

Listed CPT and Unlisted CodesCPTCovered

00580	Anesthesia for heart transplant or heart/lung transplant
00796	Anesthesia for intraperitoneal procedures in upper abdomen; liver transplant (recipient)
15769	Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
15825	Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)
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
15835	Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock

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Craniofacial reconstruction codesCPTCovered

21184	Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra-and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining
21188	Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)

Facial grafts/augmentations/revisionsCPTCovered

21230	Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)
21235	Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)
21247	Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)
21255	Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)
21256	Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia)
21270	Malar augmentation, prosthetic material
21275	Secondary revision of orbitocraniofacial reconstruction

Pectus and spine unlisted codesCPTCovered

21740	Reconstructive repair of pectus excavatum or carinatum
21742	Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy
21743	Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with [thoracoscopy?]
22899	Unlisted procedure, spine [various specified uses]

Rhinoplasty, nasal and various unlisted surgical codesCPTCovered

22999	Unlisted procedure, abdomen, musculoskeletal system [when specified as repair of diastasis recti]
27599	Unlisted procedure, femur or knee [when specified as implantation of a medial knee implanted shock absorber or other specified implants]
28899	Unlisted procedure, foot or toes [when specified as cryoablation of plantar fasciitis or plantar fibroma]
29999	Unlisted procedure, arthroscopy [when specified as tendon repair using BioBrace implant or other specified uses]
30120	Excision or surgical planing of skin of nose for rhinophyma
30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
30410	Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or
30420	Rhinoplasty, primary; including major septal repair
30450	Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)

ENT, transplant, cardiac, vascular, and hematopoietic procedure codesmixedCovered

30999	Unlisted procedure, nose [various specified uses including nasal valve suspension, minimally invasive posterior nasal nerve treatment]
31299	Unlisted procedure, accessory sinuses [specified uses including sinus dilation systems]
31599	Unlisted procedure, Larynx (references WPATH Standards of Care)
32850	Donor pneumonectomy(s) (including cold preservation)
32851-32856	Various lung transplant procedures and backbench preparations
33140-33141	Transmyocardial laser revascularization codes
33225	Insertion of pacing electrode, cardiac venous system, for left ventricular pacing
33267-33269	Exclusion of left atrial appendage (open and thoracoscopic)
33340	Percutaneous transcatheter closure of the left atrial appendage with endocardial implant
33361-33370	Transcatheter aortic valve replacement and related procedures

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Unlisted cardiacCPT

33999

Transplant / CAR-T related CPT codesCPTCovered

38204	Management of recipient hematopoietic progenitor cell donor search and cell acquisition
38205	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic
38206	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous
38207	Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage
38208	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor
38209	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor
38210	Transplant preparation of hematopoietic progenitor cells
38211	Transplant preparation of hematopoietic progenitor cells
38212	Transplant preparation of hematopoietic progenitor cells
38213	Transplant preparation of hematopoietic progenitor cells

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Unlisted palate/uvulaCPT

42299

Bariatric surgery and related codesCPTCovered

43632	Gastrectomy, partial, distal; with gastrojejunostomy (Billroth II) [when specified as bariatric surgery]
43633	Gastrectomy, partial, distal; with Roux-en-Y reconstruction [when specified as bariatric surgery]
43644	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
43645	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
43659	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]
43771	Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only
43775	Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)
43843	Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
43845	Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)
43846	Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy

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Intestinal donor/transplant codesCPTCovered

44132	Donor enterectomy (including cold preservation), open; from cadaver donor
44133	Donor enterectomy (including cold preservation), open; partial, from living donor
44135	Intestinal allotransplantation; from cadaver donor
44136	Intestinal allotransplantation; from living donor

Liver, pancreas, renal, transplant and urethroplasty codesmixedCovered

47370	Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency
47371	Laparoscopy, surgical, ablation of 1 or more liver tumor(s); cryosurgical
47380	Ablation, open, of 1 or more liver tumor(s); radiofrequency
47381	Ablation, open, of 1 or more liver tumor(s); cryosurgical
47382	Ablation, 1 or more liver tumor(s), percutaneous
47383	Ablation, 1 or more liver tumor(s), percutaneous
47384	Ablation, irreversible electroporation, liver, 1 or more tumors, including imaging guidance, percutaneous
47399	Unlisted procedure, liver
48550	Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation
48551	Backbench standard preparation of cadaver donor pancreas allograft

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Transplant-related CPT codesCPTCovered

50325	Preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary
50327	Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis
50328	Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis
50329	Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis
50340	Recipient nephrectomy (separate procedure)
50360	Renal allotransplantation, implantation of graft; without recipient nephrectomy
50365	Renal allotransplantation, implantation of graft; with recipient nephrectomy
50547	Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor

Genitourinary and male genital CPT codes (includes transgender-related)CPTCovered

53410	Urethroplasty, 1-stage reconstruction of male anterior urethra
53420	Urethroplasty, 2-stage reconstruction or repair of prostatic
53425	Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second stage
53430	Urethroplasty, reconstruction of female urethra
53448	Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session
53899	Unlisted procedure, urinary system [when specified as TULSA or portable normothermic organ perfusion system for kidney]
54125	Amputation of penis; complete
54440	Plastic operation of penis for injury
54520	Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach
54660	Insertion of testicular prosthesis (separate procedure)

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Female genital, gynecologic, and related CPT codes (includes many WPATH-referenced items)CPTCovered

56625	Vulvectomy simple; complete
56800	Plastic repair of introitus
56805	Clitoroplasty for intersex state
57110	Vaginectomy, complete removal of vaginal wall
57291	Construction of artificial vagina; without graft
57292	Construction of artificial vagina; with graft
57296	Revision (including removal) of prosthetic vaginal graft
57335	Vaginoplasty for intersex state
57426	Revision (including removal) of prosthetic vaginal graft
58140	Myomectomy, abdominal approach, 1-4 intramural myomas, total weight ≤250 g

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Neurosurgical, neurostimulation, and nerve procedure CPT codesCPTCovered

61630	Balloon angioplasty, intracranial, percutaneous
61635	Transcatheter placement of intravascular stent(s), intracranial
61736	LITT of lesion, intracranial; single
61737	LITT of lesion, intracranial; multiple
61850	Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical
61860	Craniectomy or craniotomy for implantation of neurostimulator electrodes
61863	Stereotactic implantation of neurostimulator electrode array in subcortical site without intraoperative microelectrode
61864	Each additional array (implantation)
61867	Stereotactic implantation with intraoperative microelectrode recording; first array
61868	Each additional array with intraoperative microelectrode recording

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Selected ENT/Facial/Transgender-related CPT and unlisted codesCPT

64864	Suture of facial nerve; extracranial.
64865	Suture of facial nerve; infratemporal, with or without grafting.
64866	Anastomosis; facial-spinal accessory.
64868	Anastomosis; facial-hypoglossal.
64999	Unlisted procedure — multiple specified implant/neuromodulation/neurosurgery uses referenced.
69090	Ear piercing.
69300	Otoplasty, protruding ear, with or without size reduction.
69399	Unlisted procedure, external ear (other specified).
69799	Unlisted procedure, middle ear (specified as implantation of hearing aids or balloon dilation of eustachian tube).
69949	Unlisted procedure, inner ear (specified uses).

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Biomarker testing prior auth policy exception (CA SB 535)

ScopeApplies to biomarker testing including cancer progression and recurrence testing for advanced/metastatic stage 3 or 4 cancer members

Provider actionVerify member’s cancer stage when submitting biomarker testing claims; do not perform post-service medical necessity denials for qualifying tests

ReferenceEffective July 1, 2022 California statute compliance (SB 535) — Anthem policy statement

Haller Index

DefinitionHaller Index — CT-derived index required or referenced for authorization of reconstructive pectus repair codes 21740, 21742, 21743

Required submissionHaller Index value and CT report must be submitted via Availity with prior authorization requests for pectus repair codes

Affected codes21740, 21742, 21743

BMI submission

Required elementSubmit patient BMI as part of bariatric surgery precertification documentation (examples: 43632, 43633, 43644, 43645, 43775, 43843)

Supporting docsNutritional consult, past participation in weight management program, pre- and post-op education and treatment plan, medical/mental clearance

Submission channelVia www.availity.com as specified in code comments

Uterus weight threshold

Uterus weight threshold250 g — used for code selection and guideline application for myomectomy and hysterectomy codes (eg, 58140, 58146, 58552, 58554, 58570–58574 variants)

Codes referencing threshold58140, 58146, 58150 series, 58260 series, 58541–58546, 58570–58574 (see code entries)

Provider actionInclude uterus weight (grams) in preauthorization documentation when applicable

remote interrogation monitoring period

Remote interrogation monitoring periodUp to 90 days for remote interrogation device evaluations (e.g., 0929T, 0948T, 0949T) per SURG.00153

Left atrial pressure monitoring windowUp to 30 days for left atrial pressure sensor data reporting and interpretation (e.g., 0934T) per SURG.00128

SubmissionRequests reference the named surgical guideline (SURG.00153 or SURG.00128) and require prior authorization

left atrial pressure monitoring data window

Left atrial pressure monitoring data windowUp to 30 days of daily uploads, interpretation and trend analysis for left atrial pressure sensor (code 0934T) per SURG.00128

Associated procedureTranscatheter implantation of wireless left atrial pressure sensor (0933T) with subsequent data window defined by 0934T

DocumentationPrior authorization required; follow SURG.00128 criteria and submit via Availity as instructed

BMI and weight management documentation example (C9785)

GuidelineC9785 references CG-SURG-83 for bariatric/endoscopic sleeve gastroplasty

Provider actionInclude specified preauthorization documents to align with CG-SURG-83 criteria

Weight capacity thresholds for mobility codes

Provider actionDocument patient weight and select appropriate K-code matching capacity; include prosthetist evaluation via Availity when required

Reference guidelineCG-DME-31 governs prior authorization and clinical criteria for power wheelchairs

Wound surface area thresholds for skin substitute application

Affected codes15271–15278 and 15150–15157 (tissue cultured autografts) — per code comments

Provider actionReport total wound surface area and apply correct incremental codes when requesting prior authorization

Fat graft injectate volume thresholds

Coding guidanceSelect primary code based on initial injectate volume and add incremental code(s) for additional volume as specified

DocumentationInclude volume injected and operative notes in prior authorization submission; reference CG-SURG-123 and WPATH when applicable

Skin substitute wound size threshold

Smaller wound thresholdFirst 25 sq cm and additional 25 sq cm increments apply for smaller wound codes (15271–15272, 15275–15276)

Provider actionReport wound measurements (sq cm) and body area percentage for pediatric cases when requesting authorization

Autologous fat graft injectate increments

Example codes15771 (≤50 cc), 15772 (each additional 50 cc), 15773 (≤25 cc face), 15774 (each additional 25 cc face)

Submission requirementInclude injected volume details in prior authorization documentation and operative report

Uterus weight threshold for code assignment — 250 g (repeat)

Affected codes58140, 58146, 58541–58546, 58570–58574, 58260 series (vaginal hysterectomy variants) — note code comments referencing 250 g

Provider actionDocument uterus weight (grams) in preauthorization request and operative reports when applicable

Precertification required for listed plastic/reconstructive codes

Required Provider Submissions and Risk of Denial

Prior Authorization

Precertification required for listed plastic/reconstructive codes

Obtain precertification/prior authorization before performing listed procedures.
Follow the specific Criteria/Guideline referenced next to each code (e.g., ANC.00008, ANC.00009, SURG.00023, CG-SURG-*).
Submit supporting documents via www.availity.com where comments specify.

Prior Authorization

Facial/orbital/craniofacial reconstruction codes — prior authorization & submission

Submit photos via www.availity.com for ANC.00008-linked reviews.
For CG-SURG-84-linked codes submit x-rays and tracings via Availity as instructed.

Prior Authorization

Autograft and midface reconstruction codes — prior authorization & supporting docs

Upload photos via www.availity.com for ANC.00008-linked requests.
Submit x-rays and tracings for CG-SURG-84–referenced reconstructions as noted.

Prior Authorization

Orbit/augmentation/revision codes — prior authorization & documentation

Submit photos via www.availity.com for ANC.00008 reviews.
For transgender surgeries include a mental health letter and plastics evaluation via Availity.

Documentation Required

Pectus repair codes — include Haller Index/CT with prior auth

Include Haller Index +/- CT report with the prior authorization submission via Availity.
Follow ANC.00009 guidance referenced next to each pectus code.

Prior Authorization

Rhinoplasty and nasal procedure codes — prior authorization & photos

Upload clinical photos via www.availity.com as indicated in code comments.
For transgender surgeries include mental health letter and plastics evaluation via Availity per WPATH guidance.

Prior Authorization

Other specialty and unlisted procedure codes — prior authorization

Obtain prior authorization per the cited guideline on the code line.
If comments direct, contact the Anthem Transplant Unit (888-574-7215) for transplant/CAR-T related codes.

Prior Authorization

Transplant / CAR-T related codes — prior authorization & transplant unit contact

Call Anthem Transplant Unit at 888-574-7215 for listed transplant/CAR-T codes.
Follow the TRANS.* or CC-* criteria referenced next to each code when requesting authorization.

Documentation Required

Bariatric surgery codes — prior authorization & pre-op documentation

Include BMI and nutritional consult documentation with the prior authorization request via www.availity.com.
Document prior participation in weight management program and required clearances per CG-SURG-83.

Prior Authorization

Precertification/Prior authorization required — assorted listed codes

Obtain prior authorization for codes marked as requiring precertification.
For transplant codes, follow contact instructions to Anthem Transplant unit when present.

Prior Authorization

Prior authorization required for listed codes — follow referenced guidelines

Use the Criteria/Guideline listed next to each code to determine documentation needs.
Upload photos, letters, or imaging via www.availity.com where comments direct.

Prior Authorization

Anthem prior authorization required — specified T/CPT codes

Anthem requires prior authorization/precertification for the CPT/T and related codes listed; follow the specified internal criteria/guidelines cited on each code when submitting requests.

Codes such as the listed T-codes require authorization per SURG.00153, SURG.00128, etc.
Consult the Criteria/Guideline referenced adjacent to each code for required materials.

Prior Authorization

Codes requiring prior authorization — follow referenced internal guidelines

The listed codes require prior authorization and are paired with Anthem internal criteria/guidelines (e.g., SURG.*, LAB.*); obtain precertification and submit documentation per the referenced policy.

Each U-code or T-code is associated with a specific LAB. or SURG. guideline—follow that guideline for documentation.
Submit requests via Availity when comments direct.

Prior Authorization

Prior authorization required for listed CPT/HCPCS/U codes

Check the Criteria/Guideline ID listed with each code to determine required supporting materials.
Submit prosthetist evaluations, prescriptions, photos, or letters via www.availity.com when specified.

Prior Authorization

Codes requiring prior authorization — HCPCS/CPT/J/K entries

These HCPCS/CPT/J/K codes are on the Anthem Local PPO precertification/prior authorization list and require prior authorization per the Criteria/Guideline referenced for each code.

Obtain prior authorization per the listed Criteria/Guideline (e.g., CG-DME-31 for many K-codes).
Follow any submission instructions provided in the code comments.

Prior Authorization

Prior authorization required — K/L/Q code groups

For power mobility (K-codes) follow CG-DME-31 and submit prosthetist evaluation and MD prescription via Availity when directed.
For L- and Q-codes follow the Criteria/Guideline cited next to each code.

Prior Authorization

Graft/allograft Q-codes — prior authorization per SURG.00011

Amniotic membrane and related graft product Q-codes require prior authorization and are governed by SURG.00011; obtain precertification and bill per square centimeter as indicated.

Request prior authorization per SURG.00011 for listed Q-codes.
Charge and document per-square-centimeter units as shown on code entries.

Documentation Required

Breast reconstruction / transgender surgery — submit mental health letter & plastics eval

Include mental health letter and plastics evaluation for transgender-related breast reconstruction submissions via Availity.
Follow SURG.00023 clinical criteria referenced next to the S-code.

Prior Authorization

Skin substitute / tissue cultured graft codes — prior authorization

Obtain authorization per CG-SURG-127 and SURG.00011 for codes like 15150–15278.
Carelon may manage authorization for eligible members; otherwise Anthem manages the review.

Prior Authorization

Autologous fat grafting — prior authorization & WPATH-linked documentation

Submit prior authorization per CG-SURG-123 for autologous fat grafting codes.
For transgender-related procedures include WPATH-aligned documentation via Availity.

Documentation Required

Micropigmentation / adjacent tissue transfer — prior authorization & documentation

Submit photos for ANC.00007 reviews via www.availity.com.
For transgender surgeries include mental health letter and plastics evaluation as specified.

Prior Authorization

Precertification required for listed plastic surgery codes — manage per responsible party

Verify whether Carelon or Anthem is the responsible prior authorization manager for the member.
Submit required documentation via Availity when code comments instruct.

Prior Authorization

Precertification required for listed reconstructive and related codes

Provide imaging, studies or other materials required by the referenced guideline (for example, sleep study or x-rays/tracings).
Confirm management assignment (Carelon vs Anthem) as noted for the code.

Prior Authorization

Prior authorization required for listed procedure codes — submit required studies

For SURG.00129-related procedures include a sleep study when required.
For CG-SURG-84-related procedures include x-rays and tracings as specified.

Prior Authorization

Prior authorization required — codes with responsible party and guideline

Do not submit claims for these codes without first obtaining required precertification when Responsible Party = Anthem.
If code comments indicate Carelon management, verify member eligibility and submit to the correct vendor if applicable.

Prior Authorization

Precertification required for listed codes — Carelon vs Anthem management

Verify whether the member’s plan is managed by Carelon for outpatient/vendor program handling.
If not eligible for vendor program, submit prior authorization to Anthem per the code comments.

Documentation Required

Required supporting documents for reviews — photos, MH letters, plastics evals

Upload clinical photos to www.availity.com when code comments direct (ANC.00008/ANC.00009/ANC.00007).
For transgender surgeries submit mental health letter(s) and a plastics evaluation via Availity as specified.

Documentation Required

Photos and mental health/plastics evaluation — submit via Availity for ANC.00008/WPATH-linked codes

Photos must be uploaded via Availity when ANC.00008/ANC.00009 comments require them.
Transgender surgery submissions must include the mental health letter and plastics evaluation via Availity as noted.

Documentation Required

Imaging requirement (Pectus) — submit Haller Index and CT report via Availity

For reconstructive pectus repair codes (21740, 21742, 21743) include the Haller Index and the CT report (when applicable) with the prior authorization submission via www.availity.com per ANC.00009.

Provide numeric Haller Index and attach CT report to support medical necessity.
Submit these documents through the Availity portal as instructed.

Documentation Required

Bariatric pre-op documentation — BMI, nutrition, weight-management history

Include BMI and documented weight-management participation history.
Attach nutritional consult notes and pre/post-op education materials via Availity.

Billing Rule

Transplant unit contact — call 888-574-7215 and submit TRANS.* documentation

Call Anthem Transplant Unit at 888-574-7215 for transplant/CAR-T authorization guidance.
Provide the TRANS.*–referenced documentation when submitting the authorization request.

Documentation Required

Sleep study submission — include sleep study for palatal/sleep-related procedures

For palatal/sleep-related procedures (e.g., 42299 and SURG.00129-linked codes) include and submit the relevant sleep study via www.availity.com as part of the prior authorization request.

Attach the diagnostic sleep study report via Availity when SURG.00129 is referenced.
Omission of the sleep study may affect authorization decisions.

Documentation Required

Photos and mental health letters via Availity — for transgender surgeries and ANC.00009 items

Submit two mental health letters via Availity where the code comments require two letters.
Upload clinical photos via Availity when requested for ANC.00008/ANC.00009 reviews.

Documentation Required

Required submission materials for ANC.00008 / WPATH — photos, MH letter, plastics eval

Upload photos for ANC.00008 reviews via Availity.
Include mental health letter and plastics evaluation for transgender surgeries via Availity.

Documentation Required

Additional documentation for complex surgical/transplant codes — contact/unit & pre-op materials

Contact Anthem Transplant Unit when code comments indicate TRANS.* involvement.
Provide the expanded pre-op documentation via Availity as noted in the comments.

Documentation Required

Documentation must follow the referenced internal guideline

Reference the Criteria/Guideline ID listed next to the code to locate the specific policy.
Provide documentation required by that guideline when requesting authorization.

Documentation Required

Required preauthorization documentation (example: C9785)

Include BMI and weight-management participation documentation.
Attach nutrition consult and pre/post-op education materials via Availity.

Billing Rule

Unclassified drug/specialty therapy handling — contact transplant unit / specialty routing

Call Anthem Transplant Unit at 888-574-7215 for gene therapy/specialty biologic prior authorization guidance.
If codes are used for specialty pharmacy products, follow Carelon/CarelonRx routing instructions where indicated.

Documentation Required

Required documentation via Availity for prosthetics/orthotics

Upload prosthetist evaluation and MD prescription with pricing via Availity for K/L codes as instructed.
Attach photos for items like L8045 when required.

Prior Authorization

Contact/transplant unit instructions — CAR-T and cellular therapy Q-codes

Contact Anthem Transplant Unit at 888-574-7215 for CAR-T prior authorization processing.
Provide documentation required by CC-0150/CC-0151 or other CC-* criteria as referenced.

Documentation Required

Transgender surgery documentation — mental health letter and plastics evaluation required

Include required mental health letter(s) and plastics evaluation with the prior authorization submission via Availity.
Some transgender surgery code comments specify two mental health letters—follow the code-specific instruction.

Billing Rule

Transplant documentation/contact — call Anthem Transplant Unit

For transplant-related procedures and cellular therapies, contact the Anthem Transplant Unit at 888-574-7215 as noted in code comments when submitting prior authorization requests.

Call 888-574-7215 to coordinate transplant or cellular therapy authorizations.
Provide the TRANS.*–referenced documentation during the authorization process.

Documentation Required

Required supporting documentation — photos, visual fields, x-rays/tracings

Upload photos and visual field testing for blepharoplasty (15820–15823) where requested.
Submit x-rays and tracings for CG-SURG-84–linked orthognathic codes via Availity.

Documentation Required

Required documentation for specific guideline reviews — sleep study, imaging, WPATH materials

Attach sleep study reports when SURG.00129 is referenced.
Provide x-rays/tracings for CG-SURG-84 and WPATH-aligned documentation for transgender surgeries.

Note

Documentation must follow the referenced internal guideline

Consult the named Criteria/Guideline (e.g., SURG.*, CG-SURG-*, LAB.*) for per-code medical necessity requirements.
Submit the documentation specified by the referenced guideline with the prior authorization request.

Documentation Required

Bariatric and endoscopic bariatric submission requirements — BMI and weight-management documentation

Include BMI and documented evidence of weight-management program participation.
Attach nutrition consult notes and pre/post-op education materials.

Documentation Required

Photos and 2 mental health letters required for ANC.00009 / transgender surgeries

Submit two mental health letters via Availity where code comments require them.
Upload photos for ANC.00009 reviews when requested.

Documentation Required

Required documentation for ANC.00009 and transgender surgeries — photos and two MH letters

Upload requested clinical photos via Availity for ANC.00009 reviews.
Where required, include two mental health letters for transgender surgery review.

Documentation Required

Sleep study submission for SURG.00129 and related device reviews

For sleep disorder management and SURG.00129–related device reviews, submit the diagnostic sleep study via www.availity.com as part of the prior authorization package when requested.

Attach sleep study reports via Availity for SURG.00129-linked authorizations.
Omission of the sleep study may delay or affect authorization decisions.

Denial Risk

Verification and precertification risk — confirm benefits and obtain precert

Verify member benefits and eligibility prior to scheduling services.
Obtain required precertification; absence of precertification may result in denial.

Denial Risk

Missing required Haller Index/CT may cause denial — pectus repair codes

Submissions for reconstructive pectus repair (21740, 21742, 21743) must include the Haller Index and CT report when required; omission of these imaging items may lead to denial of the request.

Include Haller Index and CT report in the prior authorization submission via Availity.
Missing Haller Index/CT may result in denial.

Denial Risk

Missing supporting documentation — risk of denial or delay

Upload all documentation specified in the code comments via Availity.
Lack of required documentation may trigger denial or require additional review time.

Denial Risk

Prior authorization required for Anthem-responsible codes — risk of denial if not obtained

Check the Responsible Party assignment and obtain authorization from Anthem when indicated.
Claims submitted without required precertification for Anthem-managed codes may be denied.

Prior Authorization

Preauthorization required for listed procedural (T) codes — obtain per SURG.*

Obtain authorization per the SURG.* guideline referenced for T-codes.
Submit any required supporting documentation indicated by the guideline.

Prior Authorization

Preauthorization required for listed laboratory (U) codes — follow LAB.* guidance

Refer to the LAB.* guideline referenced next to each U-code to determine required documentation.
Submit prior authorization requests for U-codes to Anthem as indicated.

Documentation Required

Documentation requirement may affect authorization — implantable breast prosthesis and WPATH

Submit mental health letter and plastics evaluation for implantable breast prosthesis when the code comments reference WPATH.
Failure to provide required documentation may prevent authorization under the referenced guideline.

Billing Rule

Transplant/specialty drug contact requirement — contact Anthem Transplant Unit when indicated

Contact Anthem Transplant Unit at 888-574-7215 when code comments instruct.
Provide any transplant-specific documentation required by TRANS.* criteria.

Billing Rule

Submission requirements for selected L/K codes — prosthetist evaluation and MD prescription

Upload prosthetist evaluation, MD prescription and pricing information via Availity as instructed.
Missing these items may cause claim denial or authorization delays.

Denial Risk

Missing transgender documentation — mental health letters/plastics eval required

Include required mental health documentation and plastics evaluation via Availity for transgender surgeries.
Omitting required materials may prevent processing under the WPATH-linked review pathway.

Denial Risk

Transplant unit contact required — call 888-574-7215 or risk delay/denial

Phone Anthem Transplant Unit at 888-574-7215 for transplant-related prior authorization coordination.
Follow TRANS.* guidance and supply requested transplant documentation.

Documentation Required

Documentation triggers for blepharoplasty — photos and visual fields required

Attach clinical photos and visual field test results via www.availity.com for blepharoplasty reviews.
Missing these items can lead to non-approval or additional review.

Denial Risk

Transgender surgery submission risk — missing MH letter/plastics eval prevents WPATH review

Submit the mental health letter(s) and plastics evaluation via www.availity.com when required by code comments.
Failure to include these documents will prevent review under WPATH-aligned pathways.

Documentation Required

Sleep study requirement — include sleep study for SURG.00129-linked procedures

For SURG.00129-related orthognathic or sleep-related procedures, include the required sleep study with the prior authorization; omission of a sleep study may affect authorization decisions.

Attach sleep study via www.availity.com when SURG.00129 is referenced.
Missing sleep study data can lead to denial or need for additional review.

Denial Risk

Missing required documentation may lead to denial — provide guideline-specified materials

Ensure all guideline-specified documents accompany the prior authorization request via Availity.
Incomplete submissions may be denied or routed for supplemental review.