Anthem Blue Cross Blue Shield of Colorado prior authorization, page 27
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 |
|---|---|---|
| 57295 | Revision (including removal) of prosthetic vaginal graft, vaginal approach | Colorado Prior Authorization List, Pg 64 Original policy |
| 57300 | Closure, Rectovaginal Fistula; Vaginal/Transanal Approach | Colorado Prior Authorization List, Pg 65 Original policy |
| 57335 | Vaginoplasty, Intersex State | Colorado Prior Authorization List, Pg 65 Original policy |
| 57400 | Dilation of vagina under anesthesia (other than local) | Colorado Prior Authorization List, Pg 65 Original policy |
| 57410 | Pelvic examination under anesthesia (other than local) | Colorado Prior Authorization List, Pg 65 Original policy |
| 57415 | Removal of impacted vaginal foreign body (separate procedure) under anesthesia (other than local) | Colorado Prior Authorization List, Pg 65 Original policy |
| 57420 | Colposcopy, Entire Vagina, W/Cervix If Present | Colorado Prior Authorization List, Pg 65 Original policy |
| 57421 | Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix | Colorado Prior Authorization List, Pg 65 Original policy |
| 57423 | Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach | Colorado Prior Authorization List, Pg 65 Original policy |
| 57425 | Laparoscopy, Surgical, Colpopexy (Suspension of Vaginal Apex) | Colorado Prior Authorization List, Pg 65 Original policy |
| 57452 | Colposcopy, Cervix W/Upper Adjacent Vagina | Colorado Prior Authorization List, Pg 65 Original policy |
| 57454 | Colposcopy, Cervix W/Upper Adjacent Vagina; W/Biopsy(S), Cervix & Endocervical Curettage | Colorado Prior Authorization List, Pg 65 Original policy |
| 57456 | Colposcopy, Cervix W/Upper Adjacent Vagina; W/Endocervical Curettage | Colorado Prior Authorization List, Pg 65 Original policy |
| 57461 | Colposcopy, Cervix W/Upper Adjacent Vagina; W/Loop Electrode Conization, Cervix | Colorado Prior Authorization List, Pg 65 Original policy |
| 57500 | Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure) | Colorado Prior Authorization List, Pg 65 Original policy |
| 57505 | Endocervical Curettage (Not Done As Part Of A Dilation & Curettage) | Colorado Prior Authorization List, Pg 65 Original policy |
| 57510 | Cauterization, Cervix; Electro/Thermal | Colorado Prior Authorization List, Pg 65 Original policy |
| 57511 | Cauterization, Cervix; Cryocautery, Initial/Repeat | Colorado Prior Authorization List, Pg 65 Original policy |
| 57513 | Cauterization, Cervix; Laser Ablation | Colorado Prior Authorization List, Pg 65 Original policy |
| 57520 | Conization, Cervix W/Wo Fulguration, W/Wo D&C/Repair; Cold Knife/Laser | Colorado Prior Authorization List, Pg 65 Original policy |
| 57522 | Conization, Cervix W/Wo Fulguration, W/Wo D&C/Repair; Loop | Colorado Prior Authorization List, Pg 65 Original policy |
| 57530 | Trachelectomy (Cervicectomy), Amputation, Cervix (Sep Proc) | Colorado Prior Authorization List, Pg 65 Original policy |
| 57700 | Cerclage, Uterine Cervix, Nonobstetrical | Colorado Prior Authorization List, Pg 65 Original policy |
| 57720 | Trachelorrhaphy, Plastic Repair, Uterine Cervix, Vaginal Approach | Colorado Prior Authorization List, Pg 65 Original policy |
| 57800 | Dilation, Cervical Canal, Instrumental (Sep Proc) | Colorado Prior Authorization List, Pg 65 Original policy |
| 58100 | Endometrial Bx W/Wo Endocervical Bx, W/O Dilation, Any Method (Sep Proc) | Colorado Prior Authorization List, Pg 65 Original policy |
| 58120 | Dilation & Curettage, Dx &/Or Therapeutic (Nonobstetrical) | Colorado Prior Authorization List, Pg 65 Original policy |
| 58145 | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or | Colorado Prior Authorization List, Pg 65 Original policy |
| 58152 | Total Abdominal Hysterectomy W/Wo Removal Tube(S)/Ovary(S); W/Colpo- Urethrocystopexy | Colorado Prior Authorization List, Pg 66 Original policy |
| 58180 | Supracervical Abdominal Hysterectomy, W/Wo Removal Tube(S)/Ovary(S) | Colorado Prior Authorization List, Pg 66 Original policy |
| 58200 | Total Abdominal Hysterectomy, W/Partial Vaginect, W/Pelvic Node Sample, W/Wo Rem Tubes/Ovaries | Colorado Prior Authorization List, Pg 66 Original policy |
| 58210 | Radical Abdominal Hysterectomy W/Bilat Pelvic Lymphadenectomy | Colorado Prior Authorization List, Pg 66 Original policy |
| 58240 | Pelvic Exenteration, Gynecologic Malignancy | Colorado Prior Authorization List, Pg 66 Original policy |
| 58260 | Vaginal hysterectomy, for uterus 250 g or less | Colorado Prior Authorization List, Pg 66 Original policy |
| 58262 | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s) | Colorado Prior Authorization List, Pg 66 Original policy |
| 58263 | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele | Colorado Prior Authorization List, Pg 66 Original policy |
| 58267 | Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra typ | Colorado Prior Authorization List, Pg 66 Original policy |
| 58270 | Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele | Colorado Prior Authorization List, Pg 66 Original policy |
| 58275 | Vaginal Hysterectomy, W/Total/Partial Vaginectomy | Colorado Prior Authorization List, Pg 66 Original policy |
| 58280 | Vaginal Hysterectomy; W/Total/Partial Vaginectomy; W/Repair, Enterocele | Colorado Prior Authorization List, Pg 66 Original policy |
| 58285 | Vaginal Hysterectomy; Radical | Colorado Prior Authorization List, Pg 66 Original policy |
| 58290 | Vaginal Hysterectomy, Uterus >250 Gms | Colorado Prior Authorization List, Pg 66 Original policy |
| 58291 | Vaginal Hysterectomy, Uterus >250 Gms; W/Removal, Tube(S) &/Or Ovary(S) | Colorado Prior Authorization List, Pg 66 Original policy |
| 58292 | Vaginal Hysterectomy, Uterus >250 Gms; W/Removal, Tube(S) &/Or Ovary(S) W/Repair Of Enterocele | Colorado Prior Authorization List, Pg 66 Original policy |
| 58293 | Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control | Colorado Prior Authorization List, Pg 67 Original policy |
| 58294 | Vaginal Hysterectomy, Uterus >250 Gms; W/Repair Of Enterocele | Colorado Prior Authorization List, Pg 67 Original policy |
| 58346 | Insertion, Heyman Capsules, Clinical Brachytherapy | Colorado Prior Authorization List, Pg 67 Original policy |
| 58353 | Ablation, Endometrial, Thermal, W/O Hysteroscopic Guidance | Colorado Prior Authorization List, Pg 67 Original policy |
| 58541 | Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less | Colorado Prior Authorization List, Pg 67 Original policy |
| 58542 | Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) | Colorado Prior Authorization List, Pg 67 Original policy |