Anthem Blue Cross Blue Shield of California prior authorization, page 15
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 |
|---|---|---|
| Q4318 | E-Graft, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4319 | SanoGraft, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4320 | PelloGraft, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4321 | RenoGraft, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4322 | CaregraFT, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4323 | alloPLY, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4324 | AmnioTX, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4325 | ACApatch, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4326 | WoundPlus, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4327 | DuoAmnion, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4328 | MOST, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4329 | Singlay, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4330 | TOTAL, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4331 | Axolotl Graft, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4332 | Axolotl DualGraft, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4333 | ArdeoGraft, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4336 | Artacent C, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4337 | Artacent Trident, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4338 | Artacent Velos, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4339 | Artacent VeriClen, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4340 | SimpliGraft, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4341 | SimpliMax, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4342 | TheraMend, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4343 | Dermacyte AC matrix amniotic membrane allograft, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4344 | Tri-membrane wrap, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4345 | Matrix HD allograft dermis, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4368 | AmchoThick, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4370 | AeroGuard, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4371 | NeoGuard, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4372 | AmchoPlast EXCEL, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4373 | Membrane Wrap-Lite, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4375 | Duograft AC, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4376 | Duograft AA, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4377 | Trigraft FT, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4378 | Renew FT Matrix, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4379 | AmnioDefend FT matrix, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4380 | AdvoGraft One, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4382 | AdvoGraft dual, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4383 | Axolotl Graft Ultra, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4384 | Axolotl Dualgraft Ultra, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4385 | Apollo FT, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4386 | Acesso TrifACA, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4387 | NeoThelium FT, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4388 | NeoThelium 4L, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4389 | NeoThelium 4L plus, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4390 | Ascendion, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4392 | Grafix duo, per square centimeter | California PPO Prior Authorization List, Pg 29 Original policy |
| Q4393 | SurGraft AC, per square centimeter | California PPO Prior Authorization List, Pg 30 Original policy |
| Q4394 | SurGraft ACA, per square centimeter | California PPO Prior Authorization List, Pg 30 Original policy |
| Q4395 | Acelagraft, per square centimeter | California PPO Prior Authorization List, Pg 30 Original policy |