Anthem Blue Cross Blue Shield of Colorado prior authorization, page 25
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 |
|---|---|---|
| 54055 | Destruction, Penile Lesion, Simple; Electrodesiccation | Colorado Prior Authorization List, Pg 60 Original policy |
| 54057 | Destruction, Penile Lesion, Simple; Laser Surgery | Colorado Prior Authorization List, Pg 61 Original policy |
| 54060 | Destruction, Penile Lesion, Simple; Surgical Excision | Colorado Prior Authorization List, Pg 61 Original policy |
| 54065 | Destruction, Penile Lesion, Extensive | Colorado Prior Authorization List, Pg 61 Original policy |
| 54100 | Bx Of Penis; (Sep Proc) | Colorado Prior Authorization List, Pg 61 Original policy |
| 54110 | Excision, Penile Plaque (Peyronie Disease) | Colorado Prior Authorization List, Pg 61 Original policy |
| 54150 | Circumcision, using clamp or other device with regional dorsal penile or ring block | Colorado Prior Authorization List, Pg 61 Original policy |
| 54161 | Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age | Colorado Prior Authorization List, Pg 61 Original policy |
| 54162 | Lysis/Excision, Penile Postcircumcision Adhesions | Colorado Prior Authorization List, Pg 61 Original policy |
| 54163 | Repair, Incomplete Circumcision | Colorado Prior Authorization List, Pg 61 Original policy |
| 54164 | Frenulotomy, Penis | Colorado Prior Authorization List, Pg 61 Original policy |
| 54300 | Plastic Operation, Penis, Straightening, Chordee, W/Wo Mobilization, Urethra | Colorado Prior Authorization List, Pg 61 Original policy |
| 54360 | Plastic Operation, Penis To Correct Angulation | Colorado Prior Authorization List, Pg 61 Original policy |
| 54400 | Insertion, Penile Prosthesis; Non-Inflatable (Semi-Rigid) | Colorado Prior Authorization List, Pg 61 Original policy |
| 54401 | Insertion, Penile Prosthesis; Inflatable (Self-Contained) | Colorado Prior Authorization List, Pg 61 Original policy |
| 54405 | Insertion, (Multi-Component) Inflatable Penile Prosthesis | Colorado Prior Authorization List, Pg 61 Original policy |
| 54410 | Removal & Replacement, Multi-Component Inflatable Penile Prosthesis, Same Session | Colorado Prior Authorization List, Pg 61 Original policy |
| 54411 | Removal & Replacement, Multi-Component Inflatable Penile Prosthesis, Infected, W/ Irrig & Debride | Colorado Prior Authorization List, Pg 61 Original policy |
| 54416 | Removal & Replacement, Non-Inflatable (Semi-Rigid)/Inflatable (Self-Contained) Penile Prosthesis | Colorado Prior Authorization List, Pg 61 Original policy |
| 54417 | Removal & Replace, Non-Inflatable/Inflatable Penile Prosthesis Infect, W/Irrig & Debride | Colorado Prior Authorization List, Pg 61 Original policy |
| 54440 | Plastic Operation, Penis, Injury | Colorado Prior Authorization List, Pg 61 Original policy |
| 54450 | Foreskin Manipulation W/Lysis, Preputial Adhesions & Stretching | Colorado Prior Authorization List, Pg 61 Original policy |
| 54512 | Excision, Extraparenchymal Lesion, Testis | Colorado Prior Authorization List, Pg 61 Original policy |
| 54530 | Orchiectomy, Radical, Tumor; Inguinal Approach | Colorado Prior Authorization List, Pg 61 Original policy |
| 54600 | Reduction, Torsion, Testis, Surgical, W/Wo Fixation, Contralateral Testis | Colorado Prior Authorization List, Pg 61 Original policy |
| 54640 | Orchiopexy, inguinal or scrotal approach | Colorado Prior Authorization List, Pg 61 Original policy |
| 54700 | Incision & Drainage, Epididymis, Testis &/Or Scrotal Space | Colorado Prior Authorization List, Pg 62 Original policy |
| 54830 | Excision, Local Lesion, Epididymis | Colorado Prior Authorization List, Pg 62 Original policy |
| 54840 | Excision, Spermatocele, W/Wo Epididymectomy | Colorado Prior Authorization List, Pg 62 Original policy |
| 54860 | Epididymectomy; Unilat | Colorado Prior Authorization List, Pg 62 Original policy |
| 55000 | Puncture Aspiration, Hydrocele, Tunica Vaginalis, W/Wo Injection, Medication | Colorado Prior Authorization List, Pg 62 Original policy |
| 55040 | Excision, Hydrocele; Unilat | Colorado Prior Authorization List, Pg 62 Original policy |
| 55041 | Excision, Hydrocele; Bilat | Colorado Prior Authorization List, Pg 62 Original policy |
| 55060 | Repair, Tunica Vaginalis Hydrocele (Bottle Type) | Colorado Prior Authorization List, Pg 62 Original policy |
| 55100 | Drainage, Scrotal Wall Abscess | Colorado Prior Authorization List, Pg 62 Original policy |
| 55110 | Scrotal Exploration | Colorado Prior Authorization List, Pg 62 Original policy |
| 55120 | Removal, Fb In Scrotum | Colorado Prior Authorization List, Pg 62 Original policy |
| 55250 | Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) | Colorado Prior Authorization List, Pg 62 Original policy |
| 55400 | Vasovasostomy, Vasovasorrhaphy | Colorado Prior Authorization List, Pg 62 Original policy |
| 55500 | Excision, Hydrocele, Spermatic Cord, Unilat (Sep Proc) | Colorado Prior Authorization List, Pg 62 Original policy |
| 55520 | Excision, Lesion, Spermatic Cord (Sep Proc) | Colorado Prior Authorization List, Pg 62 Original policy |
| 55540 | Excision, Varicocele/Ligation, Spermatic Veins, Varicocele; W/Hernia Repair | Colorado Prior Authorization List, Pg 62 Original policy |
| 55707 | Biopsy, prostate, transrectal, ultrasound-guided (ie, sextant, ultrasound-localized discrete lesion[s]) | Colorado Prior Authorization List, Pg 62 Original policy |
| 55708 | Biopsy, prostate, transrectal, ultrasound-guided (ie,sextant) with MRI-fusion- guidance, first targeted lesion | Colorado Prior Authorization List, Pg 62 Original policy |
| 55709 | Biopsy, prostate, transperineal, ultrasound-guided (ie, sextant, ultrasound- localized discrete lesion[s]) | Colorado Prior Authorization List, Pg 62 Original policy |
| 55710 | Biopsy, prostate, transperineal, ultrasound-guided (ie,sextant) with MRI-fusion- guidance biopsy, first targeted lesion | Colorado Prior Authorization List, Pg 62 Original policy |
| 55711 | Biopsy, prostate, transrectal, MRI-ultrasound-fusion guided, targeted lesion(s) only, first targeted lesion | Colorado Prior Authorization List, Pg 62 Original policy |
| 55712 | Biopsy, prostate, transperineal, MRI-ultrasound-fusion guided, targeted lesion(s) only, first targeted lesion | Colorado Prior Authorization List, Pg 62 Original policy |
| 55713 | Biopsy, prostate, in-bore CT- or MRI-guided (ie, sextant), with biopsy of additional targeted lesion(s), first targeted lesion | Colorado Prior Authorization List, Pg 62 Original policy |
| 55714 | Biopsy, prostate, in-bore CT- or MRI-guided targeted lesion(s) only, first targeted lesion | Colorado Prior Authorization List, Pg 62 Original policy |