Anthem Blue Cross Blue Shield of California prior authorization, page 13
CPT code lookup
Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| J3490 | Unclassified drugs or biologicals [when specified as eladocagene exuparvovec-tneq (Kebilidi)] or [when specified as an ocular gene therapy agent other than voretigene neparvovec-rzyl (Luxturna)] or [when specified as elivaldogene autotemcel (Skysona)] or [when specified as etuvetidigene autotemcel (Waskyra)] or [when specified as a gene therapy for hemophilia other than Hemgenix, Beqvez, or Roctavian] | California PPO Prior Authorization List, Pg 26 Original policy |
| J3590 | Unclassified drugs or biologicals [when specified as eladocagene exuparvovec-tneq (Kebilidi)] or [when specified as an ocular gene therapy agent other than voretigene neparvovec-rzyl (Luxturna)] or [when specified as allogeneic processed thymus tissue-agdc (RETHYMIC) implant] or [when specified as etuvetidigene autotemcel (Waskyra)] or [when specified as a gene therapy for hemophilia other than Hemgenix, Beqvez, or Roctavian] | California PPO Prior Authorization List, Pg 26 Original policy |
| J9248 | Injection, melphalan (Hepzato), 1 mg | California PPO Prior Authorization List, Pg 26 Original policy |
| J9999 | Lifileucel (Amtagvi) | California PPO Prior Authorization List, Pg 26 Original policy |
| K0010 | Standard-weight frame motorized/power wheelchair | California PPO Prior Authorization List, Pg 26 Original policy |
| K0011 | Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking | California PPO Prior Authorization List, Pg 26 Original policy |
| K0012 | Lightweight portable motorized/power wheelchair | California PPO Prior Authorization List, Pg 26 Original policy |
| K0013 | Custom motorized/power wheelchair base | California PPO Prior Authorization List, Pg 26 Original policy |
| K0014 | Other motorized/power wheelchair base | California PPO Prior Authorization List, Pg 26 Original policy |
| K0800 | Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 26 Original policy |
| K0801 | Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 26 Original policy |
| K0802 | Power operated vehicle, group 1 very heavy-duty, patient weight capacity 451 to 600 pounds | California PPO Prior Authorization List, Pg 26 Original policy |
| K0806 | Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 26 Original policy |
| K0807 | Power operated vehicle, group 2 heavy-duty, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 26 Original policy |
| K0808 | Power operated vehicle, group 2 very heavy-duty, patient weight capacity 451 to 600 pounds | California PPO Prior Authorization List, Pg 26 Original policy |
| K0812 | Power operated vehicle, not otherwise classified | California PPO Prior Authorization List, Pg 26 Original policy |
| K0813 | Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 26 Original policy |
| K0814 | Power wheelchair, group 1 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 26 Original policy |
| K0815 | Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 26 Original policy |
| K0816 | Power wheelchair, group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 26 Original policy |
| K0820 | Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 26 Original policy |
| K0821 | Power wheelchair, group 2 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 26 Original policy |
| K0822 | Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0823 | Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0824 | Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0825 | Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0826 | Power wheelchair, group 2 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0827 | Power wheelchair, group 2 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0828 | Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more | California PPO Prior Authorization List, Pg 27 Original policy |
| K0829 | Power wheelchair, group 2 extra heavy-duty, captain's chair, patient weight 601 pounds or more | California PPO Prior Authorization List, Pg 27 Original policy |
| K0830 | Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0831 | Power wheelchair, group 2 standard, seat elevator, captain's chair, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0835 | Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0836 | Power wheelchair, group 2 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0837 | Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0838 | Power wheelchair, group 2 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0839 | Power wheelchair, group 2 very heavy-duty, single power option sling/solid seat/back, patient weight capacity 451 to 600 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0840 | Power wheelchair, group 2 extra heavy-duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more | California PPO Prior Authorization List, Pg 27 Original policy |
| K0841 | Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0842 | Power wheelchair, group 2 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0843 | Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0848 | Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0849 | Power wheelchair, group 3 standard, captain's chair, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0850 | Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0851 | Power wheelchair, group 3 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0852 | Power wheelchair, group 3 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0853 | Power wheelchair, group 3 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0854 | Power wheelchair, group 3 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more | California PPO Prior Authorization List, Pg 27 Original policy |
| K0855 | Power wheelchair, group 3 extra heavy duty, captain's chair, patient weight capacity 601 pounds or more | California PPO Prior Authorization List, Pg 27 Original policy |
| K0856 | Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 27 Original policy |