Anthem Blue Cross Blue Shield of Colorado prior authorization, page 19
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 |
|---|---|---|
| 43233 | Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) | Colorado Prior Authorization List, Pg 48 Original policy |
| 43235 | Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | Colorado Prior Authorization List, Pg 48 Original policy |
| 43236 | Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance | Colorado Prior Authorization List, Pg 48 Original policy |
| 43239 | Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple | Colorado Prior Authorization List, Pg 48 Original policy |
| 43241 | Esophagogastroduodenoscopy, flexible, transoral; with insertion of intraluminal tube or catheter | Colorado Prior Authorization List, Pg 49 Original policy |
| 43243 | Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric varices | Colorado Prior Authorization List, Pg 49 Original policy |
| 43244 | Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices | Colorado Prior Authorization List, Pg 49 Original policy |
| 43245 | Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie) | Colorado Prior Authorization List, Pg 49 Original policy |
| 43246 | Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube | Colorado Prior Authorization List, Pg 49 Original policy |
| 43247 | Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body | Colorado Prior Authorization List, Pg 49 Original policy |
| 43248 | Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire | Colorado Prior Authorization List, Pg 49 Original policy |
| 43249 | Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) | Colorado Prior Authorization List, Pg 49 Original policy |
| 43250 | Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery | Colorado Prior Authorization List, Pg 49 Original policy |
| 43251 | Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique | Colorado Prior Authorization List, Pg 49 Original policy |
| 43254 | Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection | Colorado Prior Authorization List, Pg 49 Original policy |
| 43255 | Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method | Colorado Prior Authorization List, Pg 49 Original policy |
| 43257 | Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesop | Colorado Prior Authorization List, Pg 49 Original policy |
| 43258 | Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor(s), polyp(s), or other lesion(s) n | Colorado Prior Authorization List, Pg 49 Original policy |
| 43266 | Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) | Colorado Prior Authorization List, Pg 49 Original policy |
| 43270 | Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performe | Colorado Prior Authorization List, Pg 49 Original policy |
| 43281 | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of me | Colorado Prior Authorization List, Pg 49 Original policy |
| 43282 | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh | Colorado Prior Authorization List, Pg 49 Original policy |
| 43284 | Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band), including cruroplasty when performed. | Colorado Prior Authorization List, Pg 49 Original policy |
| 43285 | Removal of esophageal sphincter augmentation device | Colorado Prior Authorization List, Pg 49 Original policy |
| 43290 | Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon | Colorado Prior Authorization List, Pg 49 Original policy |
| 43291 | Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s) | Colorado Prior Authorization List, Pg 49 Original policy |
| 43332 | Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis | Colorado Prior Authorization List, Pg 50 Original policy |
| 43333 | Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis | Colorado Prior Authorization List, Pg 50 Original policy |
| 43334 | Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or other prosthesis | Colorado Prior Authorization List, Pg 50 Original policy |
| 43335 | Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; with implantation of mesh or other prosthesis | Colorado Prior Authorization List, Pg 50 Original policy |
| 43336 | Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis | Colorado Prior Authorization List, Pg 50 Original policy |
| 43337 | Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; with implantation of mesh or other prosthesis | Colorado Prior Authorization List, Pg 50 Original policy |
| 43450 | Dilation, Esophagus, Unguided Sound/Bougie, Single/Multiple Passes | Colorado Prior Authorization List, Pg 50 Original policy |
| 43453 | Dilation, Esophagus, Over Guide Wire | Colorado Prior Authorization List, Pg 50 Original policy |
| 43497 | Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM]) | Colorado Prior Authorization List, Pg 50 Original policy |
| 43631 | Gastrectomy, Partial, Distal; W/Gastroduodenostomy | Colorado Prior Authorization List, Pg 50 Original policy |
| 43632 | Gastrectomy, Partial, Distal; W/Gastrojejunostomy | Colorado Prior Authorization List, Pg 50 Original policy |
| 43633 | Gastrectomy, Partial, Distal; W/Roux-En-Y Reconstruction | Colorado Prior Authorization List, Pg 50 Original policy |
| 43770 | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric ba | Colorado Prior Authorization List, Pg 50 Original policy |
| 43772 | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only | Colorado Prior Authorization List, Pg 50 Original policy |
| 43773 | Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device c | Colorado Prior Authorization List, Pg 50 Original policy |
| 43774 | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous | Colorado Prior Authorization List, Pg 50 Original policy |
| 43842 | Gastric Restrictive Proc, W/O Gastric Bypass, Morbid Obesity; Vertical-Banded Gastroplasty | Colorado Prior Authorization List, Pg 50 Original policy |
| 43860 | Revision, Gastrojejunal Anastomosis W/Reconstruction W/Wo Part Gastrect/Bowel Resect; W/O Vagotomy | Colorado Prior Authorization List, Pg 50 Original policy |
| 43886 | Gastric restrictive procedure, open; revision of subcutaneous port component only | Colorado Prior Authorization List, Pg 50 Original policy |
| 43887 | Gastric restrictive procedure, open; removal of subcutaneous port component only | Colorado Prior Authorization List, Pg 50 Original policy |
| 43888 | Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only | Colorado Prior Authorization List, Pg 51 Original policy |
| 43999 | Unlisted Proc, Stomach | Colorado Prior Authorization List, Pg 51 Original policy |
| 44132 | Donor Enterectomy, Open, W/Prep & Maintenance, Allograft; Cadaver Donor | Colorado Prior Authorization List, Pg 51 Original policy |
| 44133 | Donor Enterectomy, Open With Prep & Maintenance, Allograft; Partial, Living Donor | Colorado Prior Authorization List, Pg 51 Original policy |