Anthem Blue Cross Blue Shield of Colorado prior authorization, page 26
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 |
|---|---|---|
| 55860 | Exposure, Prostate, Any Approach, Radiation Insertion | Colorado Prior Authorization List, Pg 62 Original policy |
| 55862 | Exposure, Prostate, Any Approach, Radiation Insertion; W/Lymph Node Bx (Limited Pelvic Lymphadenect) | Colorado Prior Authorization List, Pg 62 Original policy |
| 55865 | Exposure, Prostate, Any Approach, Radiation Insertion; W/Bilat Pelvic Lymphadenectomy | Colorado Prior Authorization List, Pg 62 Original policy |
| 55873 | Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) | Colorado Prior Authorization List, Pg 62 Original policy |
| 55874 | Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed | Colorado Prior Authorization List, Pg 63 Original policy |
| 55875 | Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without | Colorado Prior Authorization List, Pg 63 Original policy |
| 55880 | Ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance | Colorado Prior Authorization List, Pg 63 Original policy |
| 55881 | Transurethral ablation of prostate tissue, using thermal ultrasound | Colorado Prior Authorization List, Pg 63 Original policy |
| 55882 | Transurethral ablation of prostate tissue, using thermal ultrasound; with insertion of ultrasound transducer | Colorado Prior Authorization List, Pg 63 Original policy |
| 55920 | Placement of needles or catheters into pelvic organs and/or genitalia (expect prostate) for subsequent interstitial radi | Colorado Prior Authorization List, Pg 63 Original policy |
| 55970 | Intersex Surgery; Male To Female | Colorado Prior Authorization List, Pg 63 Original policy |
| 55980 | Intersex Surgery; Female To Male | Colorado Prior Authorization List, Pg 63 Original policy |
| 56405 | Incision & Drainage, Vulva/Perineal Abscess | Colorado Prior Authorization List, Pg 63 Original policy |
| 56420 | Incision & Drainage, Bartholin's Gland Abscess | Colorado Prior Authorization List, Pg 63 Original policy |
| 56440 | Marsupialization, Bartholin's Gland Cyst | Colorado Prior Authorization List, Pg 63 Original policy |
| 56441 | Lysis, Labial Adhesions | Colorado Prior Authorization List, Pg 63 Original policy |
| 56442 | Hymenotomy, simple incision | Colorado Prior Authorization List, Pg 63 Original policy |
| 56501 | Destruction, Lesion(S), Vulva; Simple | Colorado Prior Authorization List, Pg 63 Original policy |
| 56515 | Destruction, Lesion(S), Vulva; Extensive | Colorado Prior Authorization List, Pg 63 Original policy |
| 56605 | Bx, Vulva/Perineum (Sep Proc); 1 Lesion | Colorado Prior Authorization List, Pg 63 Original policy |
| 56620 | Vulvectomy Simple; Partial | Colorado Prior Authorization List, Pg 63 Original policy |
| 56700 | Partial Hymenectomy/Revision, Hymenal Ring | Colorado Prior Authorization List, Pg 63 Original policy |
| 56740 | Excision, Bartholin's Gland/Cyst | Colorado Prior Authorization List, Pg 63 Original policy |
| 56805 | Clitoroplasty, Intersex State | Colorado Prior Authorization List, Pg 63 Original policy |
| 56810 | Perineoplasty, Repair, Perineum, Nonobstetrical (Sep Proc) | Colorado Prior Authorization List, Pg 63 Original policy |
| 56821 | Colposcopy, Vulva; W/Biopsy(S) | Colorado Prior Authorization List, Pg 63 Original policy |
| 57000 | Colpotomy; W/Exploration | Colorado Prior Authorization List, Pg 63 Original policy |
| 57061 | Destruction, Vaginal Lesion(S); Simple | Colorado Prior Authorization List, Pg 63 Original policy |
| 57065 | Destruction, Vaginal Lesion(S); Extensive | Colorado Prior Authorization List, Pg 63 Original policy |
| 57100 | Bx, Vaginal Mucosa; Simple (Sep Proc) | Colorado Prior Authorization List, Pg 64 Original policy |
| 57105 | Bx, Vaginal Mucosa; Extensive, Requiring Suture (W/Cysts) | Colorado Prior Authorization List, Pg 64 Original policy |
| 57106 | Vaginectomy, Partial Removal, Vaginal Wall | Colorado Prior Authorization List, Pg 64 Original policy |
| 57130 | Excision, Vaginal Septum | Colorado Prior Authorization List, Pg 64 Original policy |
| 57135 | Excision, Vaginal Cyst/Tumor | Colorado Prior Authorization List, Pg 64 Original policy |
| 57155 | Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy | Colorado Prior Authorization List, Pg 64 Original policy |
| 57156 | Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy | Colorado Prior Authorization List, Pg 64 Original policy |
| 57210 | Colpoperineorrhaphy, Suture, Injury, Vagina &/Or Perineum (Nonobstetrical) | Colorado Prior Authorization List, Pg 64 Original policy |
| 57240 | Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when performed | Colorado Prior Authorization List, Pg 64 Original policy |
| 57250 | Posterior Colporrhaphy, Repair, Rectocele W/Wo Perineorrhaphy | Colorado Prior Authorization List, Pg 64 Original policy |
| 57260 | Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed | Colorado Prior Authorization List, Pg 64 Original policy |
| 57265 | Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed; with enterocele repair | Colorado Prior Authorization List, Pg 64 Original policy |
| 57268 | Repair, Enterocele, Vaginal Approach (Sep Proc) | Colorado Prior Authorization List, Pg 64 Original policy |
| 57270 | Repair, Enterocele, Abdominal Approach (Sep Proc) | Colorado Prior Authorization List, Pg 64 Original policy |
| 57280 | Colpopexy, Abdominal Approach | Colorado Prior Authorization List, Pg 64 Original policy |
| 57282 | Sacrospinous Ligament Fixation, Prolapse, Vagina | Colorado Prior Authorization List, Pg 64 Original policy |
| 57283 | Colpopexy, Vaginal; Intra-Peritoneal Approach (Uterosacral, Levator Myorrhaphy) | Colorado Prior Authorization List, Pg 64 Original policy |
| 57284 | Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach | Colorado Prior Authorization List, Pg 64 Original policy |
| 57285 | Paravaginal defect repair (including repair of cystocele, if performed) ;vaginal approach | Colorado Prior Authorization List, Pg 64 Original policy |
| 57287 | Removal/Revision, Sling, Stress Incontinence | Colorado Prior Authorization List, Pg 64 Original policy |
| 57288 | Sling Operation, Stress Incontinence | Colorado Prior Authorization List, Pg 64 Original policy |