Anthem Blue Cross Blue Shield of Colorado prior authorization, page 10
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 |
|---|---|---|
| 24310 | Tenotomy, Open, Elbow To Shoulder, Each Tendon | Colorado Prior Authorization List, Pg 23 Original policy |
| 24340 | Tenodesis, Biceps Tendon At Elbow (Sep Proc) | Colorado Prior Authorization List, Pg 23 Original policy |
| 24357 | Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); percutaneous | Colorado Prior Authorization List, Pg 24 Original policy |
| 24358 | Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bo | Colorado Prior Authorization List, Pg 24 Original policy |
| 24366 | Arthroplasty, Radial Head; W/Implant | Colorado Prior Authorization List, Pg 24 Original policy |
| 24515 | Open Treatment, Humeral Shaft Fx W/Plate/Screws, W/Wo Cerclage | Colorado Prior Authorization List, Pg 24 Original policy |
| 24586 | Open Treatment, Periarticular Fx/Dislocation, Elbow | Colorado Prior Authorization List, Pg 24 Original policy |
| 24665 | Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed | Colorado Prior Authorization List, Pg 24 Original policy |
| 24666 | Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed; with | Colorado Prior Authorization List, Pg 24 Original policy |
| 25000 | Incision, Extensor Tendon Sheath, Wrist | Colorado Prior Authorization List, Pg 24 Original policy |
| 25071 | Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; 3 cm or greater | Colorado Prior Authorization List, Pg 24 Original policy |
| 25073 | Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); 3 cm or greater | Colorado Prior Authorization List, Pg 24 Original policy |
| 25075 | Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; less than 3 cm | Colorado Prior Authorization List, Pg 24 Original policy |
| 25076 | Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); less than 3 cm | Colorado Prior Authorization List, Pg 24 Original policy |
| 25085 | Capsulotomy, Wrist | Colorado Prior Authorization List, Pg 24 Original policy |
| 25105 | Arthrotomy, Wrist Joint; W/Synovectomy | Colorado Prior Authorization List, Pg 24 Original policy |
| 25107 | Arthrotomy, Distal Radioulnar Joint W/Repair, Triangular Cartilage, Complex | Colorado Prior Authorization List, Pg 24 Original policy |
| 25109 | Excision of tendon, forearm and/or wrist, flexor or extensor, each | Colorado Prior Authorization List, Pg 24 Original policy |
| 25110 | Excision, Lesion, Tendon Sheath, Forearm &/Or Wrist | Colorado Prior Authorization List, Pg 24 Original policy |
| 25111 | Excision, Ganglion, Wrist (Dorsal/Volar); Primary | Colorado Prior Authorization List, Pg 24 Original policy |
| 25112 | Excision, Ganglion, Wrist (Dorsal/Volar); Recurrent | Colorado Prior Authorization List, Pg 24 Original policy |
| 25259 | Manipulation, Wrist, Under Anesthesia | Colorado Prior Authorization List, Pg 24 Original policy |
| 25605 | Closed Treatment, Distal Radial Fx/Epiphyseal Separation; W/Manipulation | Colorado Prior Authorization List, Pg 24 Original policy |
| 25606 | Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation | Colorado Prior Authorization List, Pg 24 Original policy |
| 25607 | Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation | Colorado Prior Authorization List, Pg 24 Original policy |
| 25608 | Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 2 fragments | Colorado Prior Authorization List, Pg 24 Original policy |
| 25609 | with internal fixation of 3 or more fragments | Colorado Prior Authorization List, Pg 24 Original policy |
| 25624 | Closed Treatment, Carpal Scaphoid (Navicular) Fx; W/Manipulation | Colorado Prior Authorization List, Pg 24 Original policy |
| 25628 | Open treatment of carpal scaphoid (navicular) fracture, includes internal fixation, when performed | Colorado Prior Authorization List, Pg 25 Original policy |
| 25635 | Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); with manipulation, each bone | Colorado Prior Authorization List, Pg 25 Original policy |
| 25645 | Open treatment of carpal bone fracture (other than carpal scaphoid [navicular]), each bone | Colorado Prior Authorization List, Pg 25 Original policy |
| 26160 | Excision, Lesion, Tendon Sheath/Joint Capsule, Hand/Finger | Colorado Prior Authorization List, Pg 25 Original policy |
| 26180 | Excision of tendon, finger, flexor or extensor, each tendon | Colorado Prior Authorization List, Pg 25 Original policy |
| 26200 | Excision/Curettage, Bone Cyst/Benign Tumor, Metacarpal | Colorado Prior Authorization List, Pg 25 Original policy |
| 26210 | Excision/Curettage, Bone Cyst/Benign Tumor, Phalanx, Finger | Colorado Prior Authorization List, Pg 25 Original policy |
| 26340 | Manipulation, Finger Joint, Under Anesthesia, Each Joint | Colorado Prior Authorization List, Pg 25 Original policy |
| 27006 | Tenotomy, Abductors &/Or Extensor(S), Hip, Open (Sep Proc) | Colorado Prior Authorization List, Pg 25 Original policy |
| 27043 | Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; 3 cm or greater | Colorado Prior Authorization List, Pg 25 Original policy |
| 27045 | Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); 5 cm or greater | Colorado Prior Authorization List, Pg 25 Original policy |
| 27047 | Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; less than 3 cm | Colorado Prior Authorization List, Pg 25 Original policy |
| 27048 | Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); less than 5 cm | Colorado Prior Authorization List, Pg 25 Original policy |
| 27062 | Excision; Trochanteric Bursa/Calcification | Colorado Prior Authorization List, Pg 25 Original policy |
| 27096 | Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed | Colorado Prior Authorization List, Pg 25 Original policy |
| 27120 | Acetabuloplasty | Colorado Prior Authorization List, Pg 25 Original policy |
| 27122 | Acetabuloplasty; Resection, Femoral Head | Colorado Prior Authorization List, Pg 25 Original policy |
| 27125 | Hemiarthroplasty, Hip, Partial | Colorado Prior Authorization List, Pg 25 Original policy |
| 27130 | Arthroplasty, Acetabular/Proximal Femoral Prosthetic Replacement, W/Wo Autograft/Allograft | Colorado Prior Authorization List, Pg 25 Original policy |
| 27132 | Conversion, Previous Hip Surgery To Total Hip Arthroplasty, W/Wo Autograft/Allograft | Colorado Prior Authorization List, Pg 25 Original policy |
| 27134 | Revision, Total Hip Arthroplasty; Both Components, W/Wo Autograft/Allograft | Colorado Prior Authorization List, Pg 26 Original policy |
| 27137 | Revision, Total Hip Arthroplasty; Acetabular Component Only, W/Wo Autograft/Allograft | Colorado Prior Authorization List, Pg 26 Original policy |