Anthem Blue Cross Blue Shield of Colorado policy
CG-SURG-123 Autologous Fat Grafting and Injectable Soft Tissue Fillers
CG-SURG-123 Autologous Fat Grafting and Injectable Soft Tissue Fillers is a public Anthem Blue Cross Blue Shield of Colorado policy (policy CG-SURG-123). It lists 17 CPT or HCPCS codes, 12 of them on the Anthem Blue Cross Blue Shield of Colorado prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-SURG-123
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of Colorado prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of Colorado policies |
|---|---|---|---|
| 11950 | On the list | Subq Injection, Filling Matl; 1 Cc/< | Policies naming 11950 |
| 11951 | On the list | Subq Injection, Filling Matl; 1.1 To 5.0 Cc | Policies naming 11951 |
| 11952 | On the list | Subq Injection, Filling Matl; 5.1 To 10.0 Cc | Policies naming 11952 |
| 11954 | On the list | Subq Injection, Filling Matl; > 10.0 Cc | Policies naming 11954 |
| 15771 | On the list | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate | Policies naming 15771 |
| 15772 | Not listed | Policies naming 15772 | |
| 15773 | On the list | Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate | Policies naming 15773 |
| 15774 | Not listed | Policies naming 15774 | |
| 17999 | Not listed | Policies naming 17999 | |
| 31574 | On the list | Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), unilateral | Policies naming 31574 |
| C1878 | On the list | Material for vocal cord medialization, synthetic (implantable) | Policies naming C1878 |
| D9914 | Not listed | Policies naming D9914 | |
| G0429 | On the list | Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active | Policies naming G0429 |
| L8607 | On the list | Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies | Policies naming L8607 |
| L8699 | Not listed | Policies naming L8699 | |
| Q2026 | On the list | Injection, Radiesse, 0.1ml | Policies naming Q2026 |
| Q2028 | On the list | Injection, sculptra, 0.5 mg | Policies naming Q2028 |
All Anthem Blue Cross Blue Shield of Colorado policies · Anthem Blue Cross Blue Shield of Colorado prior authorization CPT list