Anthem Blue Cross Blue Shield of Colorado prior authorization, page 12
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 |
|---|---|---|
| 28292 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with resection of proximal phalanx base, when performed, any method | Colorado Prior Authorization List, Pg 29 Original policy |
| 28295 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal metatarsal osteotomy, any method | Colorado Prior Authorization List, Pg 29 Original policy |
| 28296 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with distal metatarsal osteotomy, any method | Colorado Prior Authorization List, Pg 29 Original policy |
| 28297 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method | Colorado Prior Authorization List, Pg 29 Original policy |
| 28298 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal phalanx osteotomy, any method | Colorado Prior Authorization List, Pg 29 Original policy |
| 28299 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with double osteotomy, any method | Colorado Prior Authorization List, Pg 29 Original policy |
| 28306 | Osteotomy, Metatarsal, W/Wo Lengthening/Shortening/Ang Correction; 1st Metatarsal | Colorado Prior Authorization List, Pg 30 Original policy |
| 28307 | Osteotomy, Metatarsal, W/Wo Lengthening/Shortening/Ang Correction; 1st Metatarsal W/Autograft | Colorado Prior Authorization List, Pg 30 Original policy |
| 28308 | Osteotomy, Metatarsal, W/Wo Lengthening/Shortening/Ang Correction; Not 1st Metatarsal, Each | Colorado Prior Authorization List, Pg 30 Original policy |
| 28310 | Osteotomy, Shortening, Angular/Rotational Correction; Proximal Phalanx, 1st Toe (Sep Proc) | Colorado Prior Authorization List, Pg 30 Original policy |
| 28312 | Osteotomy, Shortening, Angular/Rotational Correction; Other Phalanges, Any Toe | Colorado Prior Authorization List, Pg 30 Original policy |
| 28315 | Sesamoidectomy, 1st Toe (Sep Proc) | Colorado Prior Authorization List, Pg 30 Original policy |
| 28446 | Open osteochondral autograft, talus (includes obtaining grafts) | Colorado Prior Authorization List, Pg 30 Original policy |
| 28750 | Arthrodesis, Great Toe; Metatarsophalangeal Joint | Colorado Prior Authorization List, Pg 30 Original policy |
| 28890 | Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guida | Colorado Prior Authorization List, Pg 30 Original policy |
| 29800 | Arthroscopy, Temporomandibular Joint, Dx W/Wo Synovial Bx (Sep Proc) | Colorado Prior Authorization List, Pg 30 Original policy |
| 29804 | Arthroscopy, Temporomandibular Joint, Surgical | Colorado Prior Authorization List, Pg 30 Original policy |
| 29805 | Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) | Colorado Prior Authorization List, Pg 30 Original policy |
| 29806 | Arthroscopy, shoulder, surgical; capsulorrhaphy | Colorado Prior Authorization List, Pg 30 Original policy |
| 29807 | Arthroscopy, shoulder, surgical; repair of SLAP lesion | Colorado Prior Authorization List, Pg 30 Original policy |
| 29819 | Arthroscopy, shoulder, surgical; with removal of loose body or foreign body | Colorado Prior Authorization List, Pg 31 Original policy |
| 29820 | Arthroscopy, shoulder, surgical; synovectomy, partial | Colorado Prior Authorization List, Pg 31 Original policy |
| 29821 | Arthroscopy, shoulder, surgical; synovectomy, complete | Colorado Prior Authorization List, Pg 31 Original policy |
| 29822 | Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, bi | Colorado Prior Authorization List, Pg 31 Original policy |
| 29823 | Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilag | Colorado Prior Authorization List, Pg 31 Original policy |
| 29824 | Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) | Colorado Prior Authorization List, Pg 31 Original policy |
| 29825 | Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation | Colorado Prior Authorization List, Pg 31 Original policy |
| 29826 | Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separatel | Colorado Prior Authorization List, Pg 31 Original policy |
| 29827 | Arthroscopy, shoulder, surgical; with rotator cuff repair | Colorado Prior Authorization List, Pg 31 Original policy |
| 29828 | Arthroscopy, shoulder, surgical; biceps tenodesis | Colorado Prior Authorization List, Pg 32 Original policy |
| 29860 | Arthroscopy, Hip, Dx W/Wo Synovial Bx (Sep Proc) | Colorado Prior Authorization List, Pg 32 Original policy |
| 29861 | Arthroscopy, Hip, Surgical; W/Removal, Loose/Foreign Body | Colorado Prior Authorization List, Pg 32 Original policy |
| 29862 | Arthroscopy, Hip, Surgical; W/Chondroplasty/Arthroplasty, &/Or Resection, Labrum | Colorado Prior Authorization List, Pg 32 Original policy |
| 29863 | Arthroscopy, Hip, Surgical; W/Synovectomy | Colorado Prior Authorization List, Pg 32 Original policy |
| 29866 | Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) | Colorado Prior Authorization List, Pg 32 Original policy |
| 29867 | Arthroscopy, Knee, Surgical; Osteochondral Allograft (Eg, Mosaicplasty) | Colorado Prior Authorization List, Pg 32 Original policy |
| 29868 | Arthroscopy, Knee, Surgical; Meniscal Transplantation (Includes Arthrotomy For Meniscal Insertion), Medial Or Lateral | Colorado Prior Authorization List, Pg 32 Original policy |
| 29870 | Arthroscopy, Knee, Dx, W/Wo Synovial Bx (Sep Proc) | Colorado Prior Authorization List, Pg 32 Original policy |
| 29871 | Arthroscopy, Knee, Surgical; Infection, Lavage & Drainage | Colorado Prior Authorization List, Pg 32 Original policy |
| 29873 | Arthroscopy, Knee, Surgical; W/Lateral Release | Colorado Prior Authorization List, Pg 32 Original policy |
| 29874 | Arthroscopy, Knee, Surgical; Removal, Loose/Fb | Colorado Prior Authorization List, Pg 33 Original policy |
| 29875 | Arthroscopy, Knee, Surgical; Synovectomy, Limited (Sep Proc) | Colorado Prior Authorization List, Pg 33 Original policy |
| 29876 | Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) | Colorado Prior Authorization List, Pg 33 Original policy |
| 29877 | Arthroscopy, Knee, Surgical; Debridement/Shaving, Articular Cartilage (Chondroplasty) | Colorado Prior Authorization List, Pg 33 Original policy |
| 29879 | Arthroscopy, Knee, Surgical; Abrasion Arthroplasty (W/Chondroplasty)/Multiple Drilling/Microfx | Colorado Prior Authorization List, Pg 33 Original policy |
| 29880 | Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same | Colorado Prior Authorization List, Pg 33 Original policy |
| 29881 | Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same o | Colorado Prior Authorization List, Pg 33 Original policy |
| 29882 | Arthroscopy, Knee, Surgical; W/Meniscus Repair, Medial/Lateral | Colorado Prior Authorization List, Pg 33 Original policy |
| 29883 | Arthroscopy, Knee, Surgical; W/Meniscus Repair, Medial & Lateral | Colorado Prior Authorization List, Pg 33 Original policy |
| 29884 | Arthroscopy, Knee, Surgical; W/Lysis, Adhesions, W/Wo Manipulation (Sep Proc) | Colorado Prior Authorization List, Pg 33 Original policy |