Anthem Blue Cross Blue Shield of California prior authorization, page 33
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 |
|---|---|---|
| Q4257 | Relese, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4258 | Enverse, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4259 | Celera dual layer or celera dual membrane, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4260 | Signature Apatch, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4261 | TAG, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4262 | Dual Layer Impax Membrane, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4263 | SurGraft TL, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4264 | Cocoon membrane, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4265 | NeoStim TL, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4266 | NeoStim membrane, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4267 | NeoStim DL, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4268 | SurGraft FT, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4269 | SurGraft XT, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4270 | Complete SL, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4271 | Complete FT, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4272 | Esano A, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4273 | Esano AAA, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4274 | Esano AC, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4275 | Esano ACA, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4276 | Orion, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4278 | EPIEFFECT, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4279 | Vendaje AC, per square centimeter | California PPO Prior Authorization List, Pg 75 Original policy |
| Q4280 | Xcell amnio matrix, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4281 | Barrera SL or Barrera DL, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4282 | Cygnus Dual, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4284 | DermaBind SL, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4287 | DermaBind DL, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4288 | DermaBind CH, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4289 | RevoShield + Amniotic Barrier, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4290 | Membrane Wrap-Hydro, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4291 | Lamellas XT, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4292 | Lamellas, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4293 | Acesso DL, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4294 | Amnio Quad-Core, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4295 | Amnio Tri-Core amniotic, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4296 | Rebound Matrix, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4297 | Emerge Matrix, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4298 | AmnioCore Pro, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4299 | AmniCore Pro+, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4300 | Acesso TL, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4301 | Activate Matrix, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4302 | Complete ACA, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4303 | Complete AA, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4304 | Grafix Plus, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4310 | Procenta, per 200 mg | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4346 | Shelter DM Matrix, per square centimeter | California PPO Prior Authorization List, Pg 76 Original policy |
| Q4347 | Rampart DL Matrix, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4348 | Sentry SL Matrix, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4349 | Mantle DL Matrix, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |
| Q4350 | Palisade DM Matrix, per square centimeter | California PPO Prior Authorization List, Pg 77 Original policy |