Anthem Blue Cross Blue Shield of California prior authorization, page 32
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 |
|---|---|---|
| Q4200 | Skin TE, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4201 | Matrion, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4202 | Keroxx (2.5g/cc), 1cc | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4203 | Derma-gide, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4204 | Xwrap, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4205 | Membrane graft or Membrane wrap, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4206 | Fluid flow or Fluid GF, 1 cc | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4208 | Novafix, per square cenitmeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4209 | Surgraft, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4211 | Amnion bio or AxoBioMembrane, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4212 | AlloGen, per cc | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4213 | Ascent, 0.5 mg | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4214 | Cellesta cord, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4215 | Axolotl Ambient or Axolotl Cryo, 0.1 mg | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4216 | Artacent cord, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4217 | Woundfix, BioWound, Woundfix Plus, BioWound Plus, Woundfix Xplus or BioWound Xplus, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4218 | Surgicord, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4219 | SurgiGRAFT-Dual, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4220 | BellaCell HD or Surederm, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4221 | Amniowrap2, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4222 | Progenamatrix, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4224 | Human health factor 10 amniotic patch (hhf10-p), per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4225 | Amniobind or DermaBind TL, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4226 | MyOwn Skin, includes harvesting and preparation procedures, per square centimeter | California PPO Prior Authorization List, Pg 73 Original policy |
| Q4227 | AmnioCore, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4229 | Cogenex amniotic membrane, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4230 | Cogenex flowable amnion, per 0.5 cc | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4232 | Corplex, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4233 | SurFactor or NuDyn, per 0.5 cc | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4234 | XCellerate, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4235 | Amniorepair or AltiPly, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4236 | CarePATCH, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4237 | Cryo-cord, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4238 | Derm-Maxx, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4239 | Amnio-Maxx or Amnio-Maxx Lite, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4240 | CoreCyte, for topical use only, per 0.5 cc | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4241 | PolyCyte, for topical use only, per 0.5 cc | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4242 | AmnioCyte Plus, per 0.5 cc | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4245 | Amniotext, per cc | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4246 | Coretext or Protext, per cc | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4247 | Amniotext patch, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4248 | Dermacyte Amniotic Membrane Allograft, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4249 | Amniply, for topical use only, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4250 | AmnioAMP-MP, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4251 | Vim, per sq cm | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4252 | Vendaje, per sq cm | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4253 | Zenith Amniotic Membrane, per sq cm | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4254 | Novafix DL, per square centimeter | California PPO Prior Authorization List, Pg 74 Original policy |
| Q4255 | REGUaRD, for topical use only, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4256 | MLG-complete, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |