CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

SHBP Precertification Code List — Anthem - SHBP UM / AIM mapping

A listing of CPT/HCPCS/PLA codes that require precertification or utilization management review under SHBP (Anthem - SHBP UM), with responsible review party assignments and cross-referenced clinical guideline/policy identifiers; intended for providers submitting precertification requests for SHBP members.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicySHBP Precertification Code List — Anthem - SHBP UM / AIM mapping

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionObtain prior authorization through AIM Specialty Health (select Anthem - SHBP UM) for any listed CPT/HCPCS/PLA code before providing the service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleCPT codes listed (partial)

multipleCodes tagged Anthem - SHBP UM

01/01/2022Document update

yesPLA / U-codes included

Part 9-15Document parts (excerpt)

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

Coverage and Utilization Management Rules

inv-01: Code mapping and review responsibility

Codes in this list are subject to prior authorization and/or clinical guideline review when performed for SHBP members.

Code-to-Guideline Mapping: Each listed CPT/HCPCS/PLA code is mapped to a responsible review party (e.g., Anthem - SHBP UM or AIM) and to one or more clinical guideline or policy identifiers (for example ANC.00007, SURG.00011, CG-SURG-71, SURG.00023).

This node records the mapping relationships used to route precertification requests and to identify the clinical guideline that defines medical necessity.

inv-02: Coverage contingent on UM program and guideline adherence

Coverage is tied to prior authorization and referenced clinical guidelines

Prior authorization linkage: Coverage and performance review are contingent on the CPT/HCPCS/PLA code being processed through the UM program assigned (for example, AIM or Anthem - SHBP UM) and meeting any referenced clinical guideline or surgical policy (e.g., CG-SURG-71, CG-SURG-84, SURG.00023).

Providers must follow the referenced guideline and obtain prior authorization through the designated UM program for codes mapped to those programs.

inv-03: Precertification/UM follow-up — coverage follows referenced Anthem/SHBP UM program or internal guideline per code

Coverage and preauthorization follow the referenced Anthem/SHBP UM program or internal clinical guideline indicated per code.

UM/Precert requirement: When a listed CPT/HCPCS/PLA code is submitted for an SHBP member, the provider must follow the Anthem - SHBP UM or AIM prior authorization process and comply with the clinical guideline(s) referenced for that code (examples include Cardiology, Sleep, CG-GENE-14, SURG policies).

Code-to-program mappings are shown in the code list; use the assigned program label to determine submission pathway and required supporting documentation.

The precertification requirement applies to SHBP members for services managed under Anthem - SHBP UM and AIM Specialty Health. This requirement does not apply when Anthem - SHBP UM is secondary coverage (for example, when Medicare is the primary insurer) as noted in the SHBP precertification overview.

This extract does not include explicit coverage exclusions; rather, it functions as a code-to-utilization-management mapping. Codes shown in the list are paired with responsible UM programs and guideline identifiers, but the excerpt does not itself state specific exclusions.

Codes annotated with a utilization management assignment (for example, entries showing Anthem - SHBP UM and linked guideline IDs such as SURG.00092 or ANC.00008) imply that coverage for those services is contingent on meeting the referenced program's prior authorization and medical necessity requirements. The list maps each CPT/HCPCS/PLA code to the UM program and guideline that should be consulted for clinical criteria.

Many entries in these chunks primarily map CPT procedure codes (for example, rhinoplasty and nasal/sinus procedures) to UM program labels and guideline references (such as Anthem - SHBP UM and CG-SURG-24/CG-SURG-87). The excerpt does not include the full clinical medical necessity criteria within these lines — it records the program and policy crosswalks used to route prior authorization.

Several unlisted procedure codes are included only when specified for particular procedures. For example, code 33999 is listed when specified as a transcatheter replacement of the tricuspid valve, and codes like 38204 or 38999 are flagged when specified as bone marrow or stem cell therapies. These unlisted codes are therefore mapped conditionally in the list.

This portion of the document emphasizes mapping procedure codes to utilization management and transplant program references (for example, entries routed to Anthem - Transplant and TRANS policy IDs). It does not provide detailed medical necessity rules in the excerpted lines, but indicates where those rules are maintained (the referenced TRANS/CG/SURG policy documents).

Unlisted procedure codes (for example, 58999) are used in the list when specified for certain female genital procedures such as vaginal rejuvenation or laser tightening procedures; these entries reference guideline/policy crosswalks (e.g., CG-SURG-79) that guide authorization or classification.

Throughout these segments the primary content is a mapping between CPT/HCPCS/PLA codes and a utilization management assignment (for example, Anthem - SHBP UM or AIM) plus cross-referenced clinical guideline or surgical policy IDs. The excerpted entries indicate which program will review the service but do not contain the full clinical medical necessity rules in-line.

Some code entries include explicit policy references or effective date markers. For example, discography-related entries reference RAD.00053 and certain device/procedure mappings include Eff 1/1/2022, indicating that separate policy text or timing information governs those codes.

Certain unlisted or multianalyte assay codes in this segment (for example, 81599, 84999) have no explicit Anthem or GENE mapping shown in the excerpt. Blank or absent mappings for proprietary or unlisted laboratory codes may indicate that coverage guidance is handled elsewhere or requires individual review.

The excerpt does not state explicit coverage exclusions for the listed codes. It serves as an index mapping each code to a UM program and guideline identifier; detailed coverage or exclusion determinations must be taken from the referenced clinical guideline or policy documents.

Overall, the document excerpt maps procedure and laboratory codes to utilization management or policy crosswalks but does not embed full clinical coverage or exclusion criteria for each code. Providers should consult the referenced clinical guideline or surgical policy identifier shown alongside each code for the detailed criteria that govern coverage decisions.

Some unlisted musculoskeletal or image-guidance codes (for example, 20999, and other unlisted CPTs) are specifically mapped to transplant or surgical policy crosswalks such as TRANS.00035 or SURG.00082, indicating special authorization routing or handling but not defining coverage exclusion in the list itself.

The list includes multiple entries annotated with guideline identifiers like ANC.00007 (and similar ANC/CG references). In other policy contexts these identifiers denote the internal clinical guideline or cosmetic/ancillary classification that contains the medical necessity criteria referenced for the codes listed here.

This segment provides code-to-program mappings and cross-references; where a specific code or guideline is needed, consult the corresponding policy or AIM pathway noted in the line-item mapping.

This segment does not list explicit Not Medically Necessary (NMN) conditions. Instead, it maps codes to UM programs and guideline references that contain medical necessity language; any NMN determinations are made by applying the referenced guideline or policy to the individual case.

CPT/HCPCS/PLA Code Lists and Coding Notes

Selected CPT Codes (orthopedics, ENT, misc)CPTCovered

27412	Autologous chondrocyte implantation, knee
27415	Osteochondral allograft, knee, open
27416	Osteochondral autograft(s), knee, open (eg, mosaicplasty)
27703	Arthroplasty, ankle; revision, total ankle
27704	Removal of ankle implant
27860	Manipulation of ankle under general anesthesia
27870	Arthrodesis, ankle, open
28110	Ostectomy, partial excision, fifth metatarsal head (bunionette)
28285	Correction, hammertoe (eg, interphalangeal fusion)
28286	Hallux rigidus correction with cheilectomy, debridement

1–10 of 165

1/17

Foot/Ankle CPT CodesCPTCovered

28110	Ostectomy, partial excision, fifth metatarsal head (bunionette)
28285	Correction, hammertoe
28286	Hallux rigidus correction with cheilectomy, debridement
28289	Hallux rigidus correction without implant
28291	Hallux rigidus correction with implant
28292	Correction, hallux valgus with sesamoidectomy/proximal procedures
28306	Metatarsal osteotomy; first metatarsal
28307	Metatarsal osteotomy; first metatarsal with autograft
28308	Metatarsal osteotomy; other than first metatarsal, each
28446	Open osteochondral autograft, talus (includes obtaining graft[s])

1–10 of 12

1/2

Arthroscopy and Minimally Invasive OrthopedicsCPTCovered

29800	Arthroscopy without synovial biopsy (separate procedure)
29804	Arthroscopy, temporomandibular joint, surgical
29866	Arthroscopy, knee; osteochondral autograft(s) (mosaicplasty)
29867	Arthroscopy, knee; osteochondral allograft (mosaicplasty)
29892	Arthroscopy; listed as AIM in source (arthroscopy, other)

Rhinoplasty / Nasal / ENT CodesCPTCovered

30120	Excision or surgical planing of skin of nose for rhinophyma
30140	Submucous resection inferior turbinate, partial or complete
30401	Rhinoplasty, primary
30402	Rhinoplasty, primary
30403	Rhinoplasty, primary
30404	Rhinoplasty, primary
30406	Rhinoplasty, primary
30407	Rhinoplasty, primary
30408	Rhinoplasty, primary
30409	Rhinoplasty, primary; complete, external parts including bony pyramid

1–10 of 40

1/4

Nasal/Sinus Endoscopy and Sinus SurgeryCPTCovered

31254	Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)
31255	Nasal/sinus endoscopy with ethmoidectomy (other)
31257	Nasal/sinus endoscopy with ethmoidectomy; total including sphenoidotomy
31267	Nasal/sinus endoscopy with maxillary antrostomy
31287	Nasal/sinus endoscopy with frontal or sphenoid procedures
31296	Nasal/sinus endoscopy with dilation (balloon); maxillary or sphenoid ostium
31297	Nasal/sinus endoscopy with dilation; sphenoid ostium

Bronchoscopy / Thoracic / Lung TransplantCPTCovered

31574	Laryngoscopy, flexible; with injection(s) for augmentation
31660	Bronchoscopy with bronchial thermoplasty, 1 lobe
31661	Bronchoscopy with bronchial thermoplasty, 2 lobes
32851	Donor pneumonectomy; cadaver donor
32852	Lung transplant, single; with cardiopulmonary bypass
32853	Lung transplant, single; without cardiopulmonary bypass
32854	Lung transplant, double; with cardiopulmonary bypass
32855	Backbench preparation of cadaver donor lung allograft, unilateral
32944	Ablation therapy for pulmonary tumor(s), percutaneous, including imaging

Cardiac Device / Pacemaker / ICD CodesCPTCovered

33203	Insertion of epicardial electrode(s); endoscopic approach
33207	Permanent pacemaker insertion; ventricular
33208	Permanent pacemaker insertion; atrial and ventricular
33211	Insertion of temporary transvenous dual chamber pacing electrodes
33213	Pacemaker pulse generator replacement; dual chamber
33214	Upgrade of pacemaker system to dual chamber
33216	Insertion of single transvenous electrode, pacemaker or ICD
33217	Insertion of dual chamber transvenous pacemaker or ICD
33225	Insertion of LV pacing lead into cardiac venous system
33226	Repositioning of previously implanted LV lead

1–10 of 20

1/2

TAVR / Structural Heart CodesCPTCovered

33361	TAVR; percutaneous femoral approach
33362	TAVR; open femoral artery approach
33363	TAVR; open axillary artery approach
33364	TAVR; open iliac artery approach
33366	TAVR with cardiopulmonary bypass support
33418	Transcatheter mitral valve repair; initial prosthesis
33419	Transcatheter mitral valve repair; additional prosthesis
33477	Transcatheter pulmonary valve implantation

Cardiac / VAD / Transplant CodesCPTCovered

33927	Implantation of total replacement heart system (artificial heart)
33928	Removal and replacement of total replacement heart system
33929	Removal of total replacement heart system for heart transplantation
33930	Donor cardiectomy-pneumonectomy (including cold preservation)
33935	Heart-lung transplant with recipient cardiectomy-pneumonectomy
33940	Donor cardiectomy (including cold preservation)
33944	Backbench preparation of cadaver donor heart allograft
33975	Insertion of ventricular assist device; extracorporeal
33979	Insertion of ventricular assist device; implantable intracorporeal
33981	Replacement of extracorporeal VAD pump(s)

1–10 of 14

1/2

Vascular / Endovascular / Apheresis CodesCPTCovered

36261	Revision of implanted intra-arterial infusion pump
36465	Ultrasound-guided vein procedures; compression maneuvers
36466	Injection of non-compounded foam sclerosant
36468	Injection(s) for spider veins
36470	Injection of sclerosing solution; single incompetent vein
36471	Injection of sclerosing solution; multiple veins same leg
36474	Endovenous ablation therapy, mechanochemical; first vein
36475	Endovenous ablation therapy, radiofrequency; first vein
36478	Endovenous ablation therapy, laser; first vein
36479	Endovenous ablation therapy, laser; subsequent veins

1–10 of 16

1/2

Endovascular Revascularization / Stents / EmbolizationCPTCovered

37216	Transcatheter stent(s), cervical carotid artery, without distal embolic protection
37220	Revascularization, endovascular, iliac artery, angioplasty
37221	Revascularization, endovascular, iliac artery, with stent
37222	Each additional ipsilateral iliac vessel; angioplasty
37223	Each additional ipsilateral iliac vessel; stent
37224	Revascularization, femoral/popliteal; angioplasty
37225	Revascularization, femoral/popliteal; atherectomy
37226	Revascularization, femoral/popliteal; stent placement
37227	Revascularization, femoral/popliteal; stent + atherectomy
37228	Revascularization, tibial/peroneal artery; angioplasty

1–10 of 26

1/3

ENT / Upper Airway and Sinus (additional)CPTCovered

31254	Nasal/sinus endoscopy with ethmoidectomy, partial (anterior)
31255	Nasal/sinus endoscopy, additional ethmoid procedures
31257	Nasal/sinus endoscopy with ethmoidectomy including sphenoidotomy
31267	Nasal/sinus endoscopy with maxillary antrostomy
31287	Nasal/sinus endoscopy with frontal sinus procedures
31296	Balloon dilation of sinus ostia; maxillary or sphenoid
31297	Balloon dilation of sphenoid ostium

Precertification, Submission and Documentation Requirements

Prior Authorization

Prior Authorization / Precertification Required

Prior authorization is required for many procedures and selected CPT/PLA/genetic codes listed in this section. When a code is routed to AIM Specialty Health (AIM), Anthem - SHBP UM, Anthem - Transplant, RBM, or other UM program, providers must obtain prior authorization or precertification from the assigned program before scheduling non-emergent services. Failure to obtain required prior authorization or precertification may result in claim denial or reduced payment.

Prior authorization required for selected CPT, PLA and genetic test codes listed in this policy (e.g., many surgical, cardiology, transplant, neurostimulation, molecular pathology and advanced imaging codes).
Precertification required for diagnostic imaging, sleep testing/therapy, radiation therapy, and other AIM-managed services — submit via AIM ProviderPortals (aimspecialtyhealth.com/goweb) selecting Anthem - SHBP UM or call AIM toll-free 866-714-1103, Monday–Friday 8:00 AM–6:00 PM ET.
Codes routed to Anthem - SHBP UM, AIM, RBM, Anthem - Transplant, or IngenioRx specialty (per-code assignment) require use of the indicated UM pathway: AIM for imaging/specialty imaging/radiation/sleep; Anthem - Transplant for transplant procedures; IngenioRx for specialty medications; RBM or other program where shown.

Document Purpose and Scope

Background: This document is an index that links CPT, HCPCS and PLA codes to SHBP precertification requirements and to the clinical guideline or surgical policy that governs review. It shows the responsible review party (for example, AIM Specialty Health or Anthem - SHBP UM) and cross-references internal policy IDs (e.g., SURG.00011, ANC.00007). Providers must use the indicated UM program and referenced guideline when preparing precertification submissions.

Program and Terminology Definitions

AIM — AIM Specialty Health defined as external specialty benefits management vendor

AIM definitionAIM Specialty Health (AIM) is an external specialty benefits management vendor used to manage prior authorization for selected Anthem - SHBP UM services; providers submit requests via AIM ProviderPortals or toll-free phone

How to submitSubmit via AIM ProviderPortals (aimspecialtyhealth.com) selecting 'Anthem - SHBP UM' or call 866-714-1103 Monday–Friday 8:00 AM–6:00 PM ET

ScopeAIM commonly manages diagnostic imaging, outpatient radiation therapy, and certain other specialty services

Criteria/Guideline — CPT codes listed with 'Criteria/ Guideline' reference mapping to policies

Criteria/Guideline mappingCPT codes in the list are shown with an associated 'Criteria/ Guideline' reference mapping to internal clinical guideline or surgical policy identifiers (e.g., ANC.00007, SURG.00011)

Document Updates

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicySHBP Precertification Code List — Anthem - SHBP UM / AIM mapping

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionObtain prior authorization through AIM Specialty Health (select Anthem - SHBP UM) for any listed CPT/HCPCS/PLA code before providing the service.

SourceLink

On This Page

Documentation Required

Required submission information

When submitting a precertification or prior authorization request, include the CPT/HCPCS/PLA code(s), relevant clinical documentation, and any referenced guideline or policy identifier shown in the code list (for example: CG-SURG-xx, SURG.xxxxx, CG-GENE-xx, TRANS.xxxxx). For PLA or multianalyte assay codes, provide the laboratory/manufacturer name and test name. For unlisted codes, provide complete procedural details and supporting documentation.

Include the specific code(s) and laterality/modifiers where applicable.
Cite the referenced clinical guideline or policy ID associated with the code (e.g., CG-SURG-83, SURG.00121, GENE.00007, TRANS.00009).
For PLA/unlisted procedure codes (e.g., 0111U, 81599, 84999, 33999), include manufacturer/lab/test name and full clinical indication to allow program review.

Note

Where to route requests

Use the program label shown with each code to determine where to route the authorization request. Examples: AIM (Anthem - SHBP UM imaging, radiation, sleep); Anthem - SHBP UM (many surgical, cardiac, ENT, neurostimulation, interventional and specialty procedures); Anthem - Transplant (organ donor/recipient/transplant preparation codes); IngenioRx for specialty medications. If a code maps to AIM and/or RBM, follow the AIM/RBM submission process and include imaging-specific documentation when requested.

AIM-managed services: diagnostic imaging, radiation therapy, outpatient sleep studies and certain cardiac imaging — submit via AIM ProviderPortals or AIM phone line.
Anthem - Transplant routed codes: notify transplant program/coordinator per TRANS policy references prior to scheduling (codes such as 32850–32856, 44132–44136, 47144–47146, 50320–50329, etc.).
Codes mapped to RBM or other utilization management programs require submission to the specified program with pertinent clinical information.

Prior Authorization

Examples of code groups requiring authorization

Selected high-risk areas and examples where prior authorization or precertification is explicitly required per the code list: ENT/nasal and upper airway procedures, cardiac and thoracic procedures including TAVR and ventricular assist devices, bariatric/gastric restrictive procedures, transplant and donor procedures, neurostimulation and neurolytic procedures, advanced imaging (AIM/RBM assigned), molecular and genetic testing (Anthem - SHBP UM assigned), and PLA/unlisted tests. Review the per-code assignment in the code list to confirm requirements for each service.

ENT/nasal/sinus codes (examples: 30110–30140, 30400–30420, 30520, 30801–30802, 31237, 31253–31257) — precertification required (Anthem - SHBP UM) and reference CG-SURG-87/ANC.00008 where shown.
Cardiac/thoracic/transplant codes (examples: 33202–33231, 33340, 33548, 32850–32856, 33945, 33975–33981, 32998, 33340, 33548, 33999) — prior authorization required; transplant codes route to Anthem - Transplant and reference TRANS policies.
Bariatric/gastric procedures (examples: 43775, 43842–43843, 43999) — prior authorization required and cross-referenced to CG-SURG-83.
Neurostimulation and neurolytic procedures (examples: 61885–61886, 62287, 62350–62351, 63663–63664, 64520, 64553, 64561, 64582, 64590, 64625–64636) — prior authorization required (Anthem - SHBP UM or AIM as shown).
Advanced imaging and related codes (examples: 70470–70542, 72295, 73200–73206, 76376–76391, 77046–77049, 77301, 77338, 77371–77372, 78814–78816) — AIM/RBM assignment requires precertification and imaging documentation.
Molecular pathology, genetic testing, and PLA codes (examples: 81120–81121, 81162–81167, 81408, 81414, 81519–81521, 81599, 89290–89291, various U-codes and PLA codes) — prior authorization required (Anthem - SHBP UM) and cite CG-GENE and GENE policy IDs; provide lab/test identifiers and clinical indication.

Denial Risk

Operational notes / Denial risk

Operational notes and denial risk: precertify emergent inpatient services via the member’s ID card customer service number as indicated; precertification requirements may not apply when Anthem - SHBP UM is secondary to Medicare or other primary coverage as noted. Unlisted or blank-mapped codes (e.g., 81599, 81479, certain unlisted CPTs) are subject to review and require detailed documentation to avoid delay or denial.

For emergent inpatient admissions, follow inpatient precertification processes per member ID instructions.
If Anthem - SHBP UM is secondary, some AIM precertification requirements may not apply—verify member benefit status.
Unlisted codes and PLA codes with missing mappings carry higher review risk; provide comprehensive operative reports, test methodology, manufacturer/lab details, and rationale for medical necessity.

PurposeThese mappings identify the guideline used by UM reviewers to assess medical necessity

Example11920 references ANC.00007 and SURG.00023 as criteria/guideline

Utilization management programs referenced for prior authorization

UM programs referencedAIM and Anthem - SHBP UM are assigned as utilization management programs for many listed CPT codes

Program labelsList shows which external/internal UM program handles prior authorization for each code (e.g., 'AIM = Anthem - SHBP UM')

Action for providersObtain precertification through the program indicated for the CPT code

Clinical guideline or internal policy identifiers referenced alongside CPT codes (CG-SURG-## / ANC.00008 / MSK / SURG.00129)

Clinical guideline identifiersCodes are cross-referenced to clinical guideline or policy IDs (e.g., CG-SURG-##, ANC.00008, SURG.00121) used by UM reviewers

Examples22867 references SURG.00092; 37242 references CG-SURG-83 with 'Eff 1/1/2022'

UseProviders should cite the referenced guideline ID when submitting precertification documentation

Anthem - SHBP UM definition — program annotation indicating code is managed under SHBP utilization management

SHBP UM annotation'Anthem - SHBP UM' denotes codes managed under the State Health Benefits Plan utilization management and typically requiring precertification

ImplicationCodes labeled Anthem - SHBP UM are routed for UM review and may be denied without prior authorization

ExamplesMultiple ENT, transplant, and surgical codes in the list are annotated Anthem - SHBP UM

ANC.00008 — internal clinical guideline/policy reference linked to specific codes (e.g., rhinoplasty CPTs)

ANC.00008ANC.00008 is an internal clinical guideline referenced for many rhinoplasty/nasal procedure CPTs to specify medical necessity criteria

Example mappingCPT 30400–30420 entries reference ANC.00008 alongside Anthem - SHBP UM

Provider actionConsult ANC.00008 when preparing precertification documentation for related ENT procedures

Anthem - SHBP UM utilization management designation

Precertification designationEntries annotated 'Anthem - SHBP UM' indicate the code is subject to precertification under the SHBP UM program

ExamplesCodes such as 33999, 36260, and 37242 are shown with Anthem - SHBP UM mapping

ConsequenceProviders must obtain prior authorization through the assigned UM program before performing these services

Unlisted procedure codes (examples and mapping behavior)

Unlisted codes handlingUnlisted procedure codes (e.g., 33999, 38204, 38999) are flagged when specified for particular procedures and mapped to TRANS or SURG policy references

Example38204 mapped to TRANS.00023/00024/00027–00031 when used for donor/harvest procedures

Provider noteWhen billing an unlisted code, include specific procedural description and referenced TRANS/SURG policy ID for precertification

Anthem - Transplant — denotes transplant program management

Anthem - TransplantDenotes that the procedure is managed through Anthem's Transplant program and associated TRANS policy references (e.g., donor/recipient transplant codes)

ExamplesCodes like 32850–32856 and 33933–33945 are routed to Anthem - Transplant and TRANS policy IDs

ActionCoordinate with Anthem Transplant program for precertification/authorization for transplant-related procedures

Anthem - SHBP UM definition fallback

Program label fallback'Anthem - SHBP UM' label is used throughout the list to indicate utilization management routing for codes

InterpretationWhere 'AIM = Anthem - SHBP UM' appears, AIM manages the SHBP UM precertification workflow

Provider implicationFollow the named program's submission pathway (AIM portal or phone) when listed

Policy/GUIDE IDs — internal cross-reference identifiers (SURG.00010, CG-SURG-61, ANC.00009)

Policy/GUIDE IDs examplesPolicy/GUIDE identifiers (e.g., SURG.00145, CG-SURG-61, ANC.00009) are used as cross-references for coverage criteria

Use in submissionsProviders should reference the listed Policy/GUIDE ID when submitting precertification documentation

Where foundGUIDE IDs are shown inline next to many CPT entries throughout the list

AIM / Anthem - SHBP UM precertification program assignment example

AIM program label'Anthem - SHBP UM = AIM' indicates AIM is the managing vendor for the SHBP UM precertification pathway for those CPTs

RBM mappingSome imaging codes are mapped 'CG-SURG-82 = RBM' indicating a different review pathway (RBM) for specific imaging policies

Provider instructionUse program label to determine whether to submit to AIM or RBM for prior authorization

Molecular pathology procedure Level 2-9 grouping descriptions

Molecular pathology levelsMolecular pathology procedures are grouped by Level 2–9 based on number of exons/genes analyzed (Level 2 small targets up to Level 9 >50 exons)

ExamplesCPT 81403 = Level 4 (single exon or >10 amplicons); CPT 81408/81414 = Level 8 (26–50 exons); CPT 81408/81414/81479 references present

PLA/U-code notePLA (U-) codes represent proprietary lab test panels and are mapped to UM/GENE policies in the list

PLA / U-code definition — Proprietary Laboratory Analyses

PLA / U-code definitionPLA/U-codes are Proprietary Laboratory Analyses that apply to a single manufacturer's or single lab's specific test (e.g., 0111U for Praxis™ Extended RAS Panel)

Provider requirementWhen submitting PLA codes, include test name, performing lab, and clinical indication as listed

UM mappingMany PLA codes are assigned 'AIM = Anthem - SHBP UM' and cross-referenced to CG-GENE policies