Anthem Blue Cross Blue Shield of California prior authorization, page 31
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 |
|---|---|---|
| Q4140 | BioDfence, per square centimeter | California PPO Prior Authorization List, Pg 70 Original policy |
| Q4141 | Alloskin AC, per square centimeter | California PPO Prior Authorization List, Pg 70 Original policy |
| Q4142 | XCM Biologic Tissue Matrix, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4143 | Repriza, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4145 | Epifix, injectable, 1 mg | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4146 | TenSIX, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4147 | Architect, Architect PX, or Architect FX, extracellular matrix, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4148 | NEOX Cord 1k, NEOX Cord RT, or Clarix Cord 1k, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4149 | Excellagen, 0.1 cc | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4150 | Allowrap DS or Dry, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4152 | DermaPure, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4153 | Dermavest and Plurivest, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4155 | NeoxFlo or ClarixFlo, 1 mg | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4156 | NEOX 100 or Clarix 100, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4157 | Revitalon, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4159 | Affinity, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4161 | Bio-connekt wound matrix, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4162 | WoundEx Flow, BioSkin Flow, 0.5 cc | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4163 | WoundEx, BioSkin, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4164 | Helicoll, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4165 | Keramatrix or Kerasorb, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4166 | Cytal, per square centimeter [formerly Matristem wound/burn matrix] | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4167 | TruSkin, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4169 | Artacent Wound, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4170 | CYGNUS, per square centimeter | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4171 | Interfyl, 1 mg | California PPO Prior Authorization List, Pg 71 Original policy |
| Q4173 | PalinGen or PalinGen Xplus, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4174 | PalinGen or ProMatrX, 0.36 mg per 0.25 cc | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4175 | Miroderm, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4176 | NeoPatch or Therion, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4177 | FlowerAmnioflo, 0.1 cc | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4178 | FlowerAmniopatch, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4179 | FlowerDerm, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4180 | Revita, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4181 | Amnio Wound, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4183 | Surgigraft, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4184 | Cellesta or Cellesta Duo, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4185 | Cellesta flowable amnion (25 mg per cc); per 0.5 cc | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4188 | Amnioarmor, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4189 | Artacent AC, 1 mg | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4190 | Artacent AC, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4191 | Restorigin, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4192 | Restorigin, 1 cc | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4193 | Coll-e-derm, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4194 | Novachor, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4195 | Puraply, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4196 | PuraPly AM, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4197 | PuraPly XT, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4198 | Genesis amniotic membrane, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |
| Q4199 | Cygnus matrix, per square centimeter | California PPO Prior Authorization List, Pg 72 Original policy |