Anthem Blue Cross Blue Shield of California prior authorization, page 14
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 |
|---|---|---|
| K0857 | Power wheelchair, group 3 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 |
| K0858 | Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0859 | Power wheelchair, group 3 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 27 Original policy |
| K0860 | Power wheelchair, group 3 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 |
| K0861 | Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0862 | Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0863 | Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0864 | Power wheelchair, group 3 extra heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more | California PPO Prior Authorization List, Pg 28 Original policy |
| K0868 | Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0869 | Power wheelchair, group 4 standard, captain's chair, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0870 | Power wheelchair, group 4 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0871 | Power wheelchair, group 4 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0877 | Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0878 | Power wheelchair, group 4 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0879 | Power wheelchair, group 4 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0880 | Power wheelchair, group 4 very heavy-duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0884 | Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0885 | Power wheelchair, group 4 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0886 | Power wheelchair, group 4 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0890 | Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0891 | Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds | California PPO Prior Authorization List, Pg 28 Original policy |
| K0898 | Power wheelchair, not otherwise classified | California PPO Prior Authorization List, Pg 28 Original policy |
| K0899 | Power mobility device, not coded by DME PDAC or does not meet criteria | California PPO Prior Authorization List, Pg 28 Original policy |
| K0900 | Customized durable medical equipment, other than wheelchair (Note: applies to any code for durable medical equipment when there is not a more specific document available) | California PPO Prior Authorization List, Pg 28 Original policy |
| L2999 | Lower extremity orthosis, not otherwise specified | California PPO Prior Authorization List, Pg 28 Original policy |
| L3999 | Upper limb orthosis, not otherwise specified [when specified as an upper extremity myoelectric orthosis] | California PPO Prior Authorization List, Pg 28 Original policy |
| L8045 | Auricular prosthesis, provided by a nonphysician | California PPO Prior Authorization List, Pg 28 Original policy |
| L8600 | Implantable breast prosthesis, silicone or equal | California PPO Prior Authorization List, Pg 28 Original policy |
| L8699 | Prosthetic implant, not otherwise specified [when specified as hybrid cochlear device, including all internal and external components] or [when describing replacement components of an auditory brain stem implant] or [when specified as a hyaluronic acid gel agent such as Juvederm or Restylane] or [when describing a prefabricated, custom-fitted auricular implant] or [when describing a custom-fabricated auricular implant] or [when specified as testicular or penile prosthesis] | California PPO Prior Authorization List, Pg 28 Original policy |
| L8702 | Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated | California PPO Prior Authorization List, Pg 28 Original policy |
| Q2041 | Axicabtagene Ciloleucel [Yescarta] | California PPO Prior Authorization List, Pg 28 Original policy |
| Q2042 | Tisagenlecleucel [Kymriah] | California PPO Prior Authorization List, Pg 28 Original policy |
| Q2054 | Lisocabtagene maraleucel [Breyanzi] | California PPO Prior Authorization List, Pg 28 Original policy |
| Q2055 | Idecabtagene vicleucel [Abecma] | California PPO Prior Authorization List, Pg 28 Original policy |
| Q2057 | Afamitresgene autoleucel (Tecelra) | California PPO Prior Authorization List, Pg 29 Original policy |
| Q2058 | Obecabtagene autoleucel (Aucatzyl) | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4285 | NuDYN DL or NuDYN DL mesh, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4286 | NuDYN SL or NuDYN SLW, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4305 | American amnion AC tri-layer, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4306 | American amnion AC, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4307 | American amnion, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4308 | Sanopellis, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4309 | VIA Matrix, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4311 | Acesso, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4312 | Acesso AC, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4313 | DermaBind FM, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4314 | Reeva FT, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4315 | RegeneLink Amniotic Membrane allograft, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4316 | AmchoPlast, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4317 | VitoGraft, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |