Anthem Blue Cross Blue Shield of Colorado prior authorization, page 23
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 |
|---|---|---|
| 49655 | Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated | Colorado Prior Authorization List, Pg 57 Original policy |
| 49656 | Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible | Colorado Prior Authorization List, Pg 57 Original policy |
| 49900 | Suture, Secondary, Abdominal Wall, Evisceration/Dehiscence | Colorado Prior Authorization List, Pg 57 Original policy |
| 50250 | Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed | Colorado Prior Authorization List, Pg 57 Original policy |
| 50300 | Donor Nephrectomy; Cadaver Donor, Unilat/Bilat W/Prep & Maintenance, Allograft | Colorado Prior Authorization List, Pg 57 Original policy |
| 50320 | Donor Nephrectomy, Open, Living Donor W/O Allograft Preparation & Maintenance | Colorado Prior Authorization List, Pg 57 Original policy |
| 50323 | Backbench Standard Preparation Of Cadaver Donor Renal Allograft | Colorado Prior Authorization List, Pg 57 Original policy |
| 50325 | Backbench Standard Preparation Of Living Donor Renal Allograft (Open Or Laparoscopic) | Colorado Prior Authorization List, Pg 57 Original policy |
| 50327 | Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Venous Anastomosis, Each | Colorado Prior Authorization List, Pg 57 Original policy |
| 50328 | Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Arterial Anastomosis, Each | Colorado Prior Authorization List, Pg 57 Original policy |
| 50329 | Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Ureteral Anastomosis, Each | Colorado Prior Authorization List, Pg 57 Original policy |
| 50340 | Recipient Nephrectomy (Sep Proc) | Colorado Prior Authorization List, Pg 57 Original policy |
| 50360 | Renal Allotransplantation, Implantation, Graft; W/O Donor & Recipient Nephrectomy | Colorado Prior Authorization List, Pg 57 Original policy |
| 50365 | Renal Allotransplantation, Implantation, Graft; W/Recipient Nephrectomy | Colorado Prior Authorization List, Pg 57 Original policy |
| 50435 | Exchange nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all | Colorado Prior Authorization List, Pg 57 Original policy |
| 50542 | Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when performed | Colorado Prior Authorization List, Pg 57 Original policy |
| 50547 | Laparoscopy, Surgical; Donor Nephrectomy, Living Donor W/O Allograft Prep & Maintenance | Colorado Prior Authorization List, Pg 57 Original policy |
| 50575 | Renal Endoscopy Through Nephrotomy/Pyelotomy; W/Endopyelotomy | Colorado Prior Authorization List, Pg 57 Original policy |
| 50590 | Lithotripsy, Extracorporeal Shock Wave | Colorado Prior Authorization List, Pg 58 Original policy |
| 50592 | Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency | Colorado Prior Authorization List, Pg 58 Original policy |
| 50593 | Ablation, renal tumor(s), unilateral, presutaneous cryotherapy | Colorado Prior Authorization List, Pg 58 Original policy |
| 50688 | Change of ureterostomy tube or externally accessible ureteral stent via ileal conduit | Colorado Prior Authorization List, Pg 58 Original policy |
| 51040 | Cystostomy, Cystotomy W/Drainage | Colorado Prior Authorization List, Pg 58 Original policy |
| 51102 | Aspiration of bladder, with insertion of suprapubic catheter | Colorado Prior Authorization List, Pg 58 Original policy |
| 51600 | Injection Proc, Cystography/Voiding Urethrocystography | Colorado Prior Authorization List, Pg 58 Original policy |
| 51610 | Injection Proc, Retrograde Urethrocystography | Colorado Prior Authorization List, Pg 58 Original policy |
| 51702 | Insertion, Temporary Indwelling Bladder Catheter; Simple | Colorado Prior Authorization List, Pg 58 Original policy |
| 51710 | Change, Cystostomy Tube; Complicated | Colorado Prior Authorization List, Pg 58 Original policy |
| 51715 | Endoscopic Injection, Implant Matl Into Submucosal Tissues, Urethra &/Or Bladder Neck | Colorado Prior Authorization List, Pg 58 Original policy |
| 51720 | Bladder instillation of anticarcinogenic agent (including retention time) | Colorado Prior Authorization List, Pg 58 Original policy |
| 51721 | Transurethral ablation transducer insertion for delivery of thermal ultrasound for prostate | Colorado Prior Authorization List, Pg 58 Original policy |
| 51726 | Complex cystometrogram (ie, calibrated electronic equipment) | Colorado Prior Authorization List, Pg 58 Original policy |
| 51728 | Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressur | Colorado Prior Authorization List, Pg 58 Original policy |
| 51729 | Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressur | Colorado Prior Authorization List, Pg 58 Original policy |
| 52000 | Cystourethroscopy (Sep Proc) | Colorado Prior Authorization List, Pg 58 Original policy |
| 52001 | Cystourethroscopy W/Irrigation & Evacuation Clots | Colorado Prior Authorization List, Pg 58 Original policy |
| 52005 | Cystourethroscopy, W/Ureteral Catheterization | Colorado Prior Authorization List, Pg 58 Original policy |
| 52007 | Cystourethroscopy, W/Ureteral Catheterization; W/Brush Bx, Ureter &/Or Renal Pelvis | Colorado Prior Authorization List, Pg 58 Original policy |
| 52204 | Cystourethroscopy, with biopsy(s) | Colorado Prior Authorization List, Pg 58 Original policy |
| 52214 | Cystourethroscopy, W/Fulguration Trigone/Bladder Neck/Prostate/Urethra/Glands | Colorado Prior Authorization List, Pg 58 Original policy |
| 52224 | Cystourethroscopy, W/Fulguration/Treatment Lesion(S) < 0.5 Cm, W/Wo Bx | Colorado Prior Authorization List, Pg 58 Original policy |
| 52234 | Cystourethroscopy, W/Fulguration &/Or Resection; Bladder Tumor(S) 0.5-2.0 Cm | Colorado Prior Authorization List, Pg 58 Original policy |
| 52235 | Cystourethroscopy, W/Fulguration &/Or Resection; Bladder Tumor(S) 2.0-5.0 Cm | Colorado Prior Authorization List, Pg 58 Original policy |
| 52240 | Cystourethroscopy, W/Fulguration &/Or Resection; Large Bladder Tumor(S) > 5.0 Cm | Colorado Prior Authorization List, Pg 59 Original policy |
| 52260 | Cystourethroscopy, W/Dilation, Bladder, Interstitial Cystitis; General/Spinal Anesthesia | Colorado Prior Authorization List, Pg 59 Original policy |
| 52265 | Cystourethroscopy, W/Dilation, Bladder, Interstitial Cystitis; Local Anesthesia | Colorado Prior Authorization List, Pg 59 Original policy |
| 52275 | Cystourethroscopy, W/Int Urethrotomy; Male | Colorado Prior Authorization List, Pg 59 Original policy |
| 52276 | Cystourethroscopy, W/Direct Vision Int Urethrotomy | Colorado Prior Authorization List, Pg 59 Original policy |
| 52281 | Cystourethroscopy, W/Calibration &/Or Dilation, Urethral Stricture/Stenosis, Male/Female | Colorado Prior Authorization List, Pg 59 Original policy |
| 52282 | Cystourethroscopy, with insertion of permanent urethral stent | Colorado Prior Authorization List, Pg 59 Original policy |