Anthem Blue Cross Blue Shield of Colorado prior authorization, page 24
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 |
|---|---|---|
| 52283 | Cystourethroscopy, W/Steroid Injection Into Stricture | Colorado Prior Authorization List, Pg 59 Original policy |
| 52285 | Cystourethroscopy, Treatment, Female Urethral Syndrome | Colorado Prior Authorization List, Pg 59 Original policy |
| 52287 | Cystourethroscopy, with injection(s) for chemodenervation of the bladder | Colorado Prior Authorization List, Pg 59 Original policy |
| 52300 | Cystourethroscopy; W/Resection/Fulguration, Orthotopic Ureterocele(S), Unilat/Bilat | Colorado Prior Authorization List, Pg 59 Original policy |
| 52310 | Cystourethroscopy, W/Removal, Fb/Calculus/Ureteral Stent; Simple | Colorado Prior Authorization List, Pg 59 Original policy |
| 52315 | Cystourethroscopy, W/Removal, Fb/Calculus/Ureteral Stent; Complicated | Colorado Prior Authorization List, Pg 59 Original policy |
| 52317 | Litholapaxy; Simple/Small (< 2.5 Cm) | Colorado Prior Authorization List, Pg 59 Original policy |
| 52318 | Litholapaxy; Complicated/Large (> 2.5 Cm) | Colorado Prior Authorization List, Pg 59 Original policy |
| 52320 | Cystourethroscopy; W/Removal, Ureteral Calculus | Colorado Prior Authorization List, Pg 59 Original policy |
| 52325 | Cystourethroscopy; W/Fragmentation, Ureteral Calculus | Colorado Prior Authorization List, Pg 59 Original policy |
| 52327 | Cystourethroscopy; W/Subureteric Injection, Implant Matl | Colorado Prior Authorization List, Pg 59 Original policy |
| 52330 | Cystourethroscopy; W/Manipulation, W/O Removal Ureteral Calculus | Colorado Prior Authorization List, Pg 59 Original policy |
| 52332 | Cystourethroscopy, W/Insertion, Indwelling Ureteral Stent | Colorado Prior Authorization List, Pg 59 Original policy |
| 52341 | Cystourethroscopy; W/Treatment Ureteral Stricture | Colorado Prior Authorization List, Pg 59 Original policy |
| 52344 | Cystourethroscopy W/Ureteroscopy; W/Treatment Ureteral Stricture | Colorado Prior Authorization List, Pg 59 Original policy |
| 52351 | Cystourethroscopy W/Ureteroscopy &/Or Pyeloscopy; Diagnostic | Colorado Prior Authorization List, Pg 59 Original policy |
| 52352 | Cystourethroscopy W/Ureteroscopy &/Or Pyeloscopy; W/Removal/Manipulation Calculus | Colorado Prior Authorization List, Pg 59 Original policy |
| 52353 | Cystourethroscopy W/Ureteroscopy &/Or Pyeloscopy; W/Lithotripsy | Colorado Prior Authorization List, Pg 59 Original policy |
| 52354 | Cystourethroscopy W/Ureteroscopy &/Or Pyeloscopy; W/Bx &/Or Fulgurate Ureteral/Renal Pelvic Lesion | Colorado Prior Authorization List, Pg 59 Original policy |
| 52356 | Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type) | Colorado Prior Authorization List, Pg 59 Original policy |
| 52450 | Transurethral Incision, Prostate | Colorado Prior Authorization List, Pg 59 Original policy |
| 52500 | Transurethral resection of bladder neck (separate procedure) | Colorado Prior Authorization List, Pg 59 Original policy |
| 52510 | Transurethral balloon dilation of the prostatic urethra | Colorado Prior Authorization List, Pg 59 Original policy |
| 52601 | Transurethral Electrosurgical Resection, Prostate, W/Control Postop Bleed, Complete | Colorado Prior Authorization List, Pg 60 Original policy |
| 52630 | Transurethral resection; residual or regrowth of obstructive prostate tissue including control of postoperative bleeding | Colorado Prior Authorization List, Pg 60 Original policy |
| 52640 | Transurethral Resection; Postoperative Bladder Neck Contracture | Colorado Prior Authorization List, Pg 60 Original policy |
| 53020 | Meatotomy, Cutting, Meatus (Sep Proc); Except Infant | Colorado Prior Authorization List, Pg 60 Original policy |
| 53200 | Bx, Urethra | Colorado Prior Authorization List, Pg 60 Original policy |
| 53230 | Excision, Urethral Diverticulum (Sep Proc); Female | Colorado Prior Authorization List, Pg 60 Original policy |
| 53260 | Excision/Fulguration; Urethral Polyp(S), Distal Urethra | Colorado Prior Authorization List, Pg 60 Original policy |
| 53265 | Excision/Fulguration; Urethral Caruncle | Colorado Prior Authorization List, Pg 60 Original policy |
| 53270 | Excision/Fulguration; Skene's Glands | Colorado Prior Authorization List, Pg 60 Original policy |
| 53440 | Sling Operation, Correction, Male Urinary Incontinence | Colorado Prior Authorization List, Pg 60 Original policy |
| 53445 | Insertion, Inflatable Urethra/Bladder Neck Sphincter, W/Placement Pump &/Or Reservoir & Cuff | Colorado Prior Authorization List, Pg 60 Original policy |
| 53446 | Removal, Inflatable Urethral/Bladder Neck Sphincter W/Pump/Reservoir/Cuff | Colorado Prior Authorization List, Pg 60 Original policy |
| 53447 | Removal & Replacement, Inflatable Sphincter W/Pump, Reservoir, Cuff, Same Session | Colorado Prior Authorization List, Pg 60 Original policy |
| 53448 | Remov & Replace Inflatable Sphincter W/Pump/Reservoir/Cuff, Infected, W/Irrig & Debride | Colorado Prior Authorization List, Pg 60 Original policy |
| 53449 | Repair, Inflatable Urethral/Bladder Neck Sphincter Device, Incl Pump/Reservoir/Cuff | Colorado Prior Authorization List, Pg 60 Original policy |
| 53450 | Urethromeatoplasty, W/Mucosal Advancement | Colorado Prior Authorization List, Pg 60 Original policy |
| 53451 | Periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance | Colorado Prior Authorization List, Pg 60 Original policy |
| 53452 | Periurethral transperineal adjustable balloon continence device; unilateral insertion, including cystourethroscopy and imaging guidance | Colorado Prior Authorization List, Pg 60 Original policy |
| 53453 | Periurethral transperineal adjustable balloon continence device; removal, each balloon | Colorado Prior Authorization List, Pg 60 Original policy |
| 53454 | Periurethral transperineal adjustable balloon continence device; percutaneous adjustment of balloon(s) fluid volume | Colorado Prior Authorization List, Pg 60 Original policy |
| 53500 | Urethrolysis, Transvaginal, Secondary, Open, Including Cystourethroscopy (Eg, Postsurgical Obstruction, Scarring) | Colorado Prior Authorization List, Pg 60 Original policy |
| 53605 | Dilation, Urethral Stricture/Vesical Neck, Male, General/Spinal Anesthesia | Colorado Prior Authorization List, Pg 60 Original policy |
| 53665 | Dilation, Female Urethra, General/Conduction (Spinal) Anesthesia | Colorado Prior Authorization List, Pg 60 Original policy |
| 53850 | Transurethral Destruction, Prostate Tissue; Microwave Thermotherapy | Colorado Prior Authorization List, Pg 60 Original policy |
| 53852 | Transurethral Destruction, Prostate Tissue; Radiofrequency Thermotherapy | Colorado Prior Authorization List, Pg 60 Original policy |
| 53860 | Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence | Colorado Prior Authorization List, Pg 60 Original policy |
| 54001 | Slitting, Prepuce, Dorsal/Lateral (Sep Proc); Except Newborn | Colorado Prior Authorization List, Pg 60 Original policy |