Anthem Blue Cross Blue Shield of Colorado prior authorization, page 28
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 |
|---|---|---|
| 58543 | Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g | Colorado Prior Authorization List, Pg 67 Original policy |
| 58544 | Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s | Colorado Prior Authorization List, Pg 67 Original policy |
| 58545 | Laparoscopy, Surg, Myomectomy; 1-4 Intramural Myomas, Total Wt 250 Gms, &/Or Remove Surface Myomas | Colorado Prior Authorization List, Pg 67 Original policy |
| 58546 | Laparoscopy, Surg, Myomectomy; 5/> Intramural Myomas &/Or Total Wt >250 Gms | Colorado Prior Authorization List, Pg 67 Original policy |
| 58548 | Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node | Colorado Prior Authorization List, Pg 67 Original policy |
| 58550 | Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus 250gms/< | Colorado Prior Authorization List, Pg 67 Original policy |
| 58553 | Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus >250gms | Colorado Prior Authorization List, Pg 67 Original policy |
| 58558 | Hysteroscopy, Surgical; W/Endometrial Bx &/Or Polypectomy W/Wo D&C | Colorado Prior Authorization List, Pg 67 Original policy |
| 58560 | Hysteroscopy, Surgical; W/Division/Resection Intrauterine Septum, Any Method | Colorado Prior Authorization List, Pg 67 Original policy |
| 58561 | Hysteroscopy, Surgical; W/Removal Leiomyomata | Colorado Prior Authorization List, Pg 67 Original policy |
| 58562 | Hysteroscopy, Surgical, W/Removal Impacted Fb | Colorado Prior Authorization List, Pg 67 Original policy |
| 58563 | Hysteroscopy, Surgical; W/Endometrial Ablation | Colorado Prior Authorization List, Pg 67 Original policy |
| 58565 | Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants | Colorado Prior Authorization List, Pg 67 Original policy |
| 58575 | Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when perfor | Colorado Prior Authorization List, Pg 67 Original policy |
| 58580 | Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency | Colorado Prior Authorization List, Pg 67 Original policy |
| 58660 | Laparoscopy, Surgical; W/Lysis, Adhesions (Salpingolysis/Ovariolysis) (Sep Proc) | Colorado Prior Authorization List, Pg 68 Original policy |
| 58661 | Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) | Colorado Prior Authorization List, Pg 68 Original policy |
| 58662 | Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by an | Colorado Prior Authorization List, Pg 68 Original policy |
| 58670 | Laparoscopy, surgical; with fulguration of oviducts (with or without transection) | Colorado Prior Authorization List, Pg 68 Original policy |
| 58671 | Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) | Colorado Prior Authorization List, Pg 68 Original policy |
| 58674 | Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency. | Colorado Prior Authorization List, Pg 68 Original policy |
| 58700 | Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) | Colorado Prior Authorization List, Pg 68 Original policy |
| 58925 | Ovarian Cystectomy, Unilat/Bilat | Colorado Prior Authorization List, Pg 68 Original policy |
| 58953 | Bilat Salpingo-Oophorect W/Omentect, Total Abdom Hyster & Radical Dissect Debulk | Colorado Prior Authorization List, Pg 68 Original policy |
| 58954 | Bilat Salping-Oophorec W/Omentec, Tl Abd Hyst & Radcl Dissec, Debul; W/Pelv & Ltd Paraaortic Lymp | Colorado Prior Authorization List, Pg 68 Original policy |
| 58956 | Bilateral Salpingo-Oophorectomy With Total Omentectomy, Total Abdominal Hysterectomy For Malignancy | Colorado Prior Authorization List, Pg 68 Original policy |
| 59200 | Insertion, Cervical Dilator (Sep Proc) | Colorado Prior Authorization List, Pg 68 Original policy |
| 60660 | Percutaneous ablation of 1 or more thyroid nodule(s) | Colorado Prior Authorization List, Pg 68 Original policy |
| 61215 | Insertion, Subq Reservoir/Pump/Infusion System, Ventricular Catheter | Colorado Prior Authorization List, Pg 68 Original policy |
| 61630 | Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous | Colorado Prior Authorization List, Pg 68 Original policy |
| 61635 | Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angiop | Colorado Prior Authorization List, Pg 68 Original policy |
| 61715 | MRI guided focused ultrasound high intensity stereotactic intracranial ablation | Colorado Prior Authorization List, Pg 68 Original policy |
| 61736 | Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 si | Colorado Prior Authorization List, Pg 68 Original policy |
| 61737 | Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; multiple trajectories for | Colorado Prior Authorization List, Pg 68 Original policy |
| 61790 | Creation, Lesion, Stereotactic, Percutaneous, Neurolytic Agent; Gasserian Ganglion | Colorado Prior Authorization List, Pg 68 Original policy |
| 61791 | Creation, Lesion, Stereotactic, Percutaneous, Neurolytic Agent; Trigeminal Medullary Tract | Colorado Prior Authorization List, Pg 69 Original policy |
| 61796 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion | Colorado Prior Authorization List, Pg 69 Original policy |
| 61798 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion | Colorado Prior Authorization List, Pg 69 Original policy |
| 61850 | Twist Drill/Burr Hole(S), Implantation, Neurostimulator Electrodes, Cortical | Colorado Prior Authorization List, Pg 69 Original policy |
| 61860 | Craniectomy/Craniotomy, Implantation, Neurostimulator Electrodes, Cerebral, Cortical | Colorado Prior Authorization List, Pg 69 Original policy |
| 61863 | Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, wo Intraop Microelectrode Recording; First Array | Colorado Prior Authorization List, Pg 69 Original policy |
| 61867 | Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, w Intraop Microelectrode Recording; First Array | Colorado Prior Authorization List, Pg 69 Original policy |
| 61885 | Subq Placement Cranial Neurostimulator Pulse Generator/Receiver; W/Connection Sngle Electrod Array | Colorado Prior Authorization List, Pg 69 Original policy |
| 61886 | Subq Placement Cranial Neurostimulator Pulse Generator/Receiver; W/Connection 2+ Electrode Arrays | Colorado Prior Authorization List, Pg 69 Original policy |
| 61889 | Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, when performed, with direct or inductive coupling, with co | Colorado Prior Authorization List, Pg 69 Original policy |
| 61891 | Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode array(s) | Colorado Prior Authorization List, Pg 69 Original policy |
| 62263 | Lysis, Perq, Epidural Adhesions, Solution Injection/Mechanical W/Radiologic Localization; 2 Days/> | Colorado Prior Authorization List, Pg 69 Original policy |
| 62264 | Lysis, Perq Epidural Adhesions, Solution Injection/Mechanical W/Radiologic Localization; 1 Day | Colorado Prior Authorization List, Pg 69 Original policy |
| 62281 | Injection/Infusion Neurolytic Substance, W/Wo Therapeutic Substance; Epidural Cervical/Thoracic | Colorado Prior Authorization List, Pg 69 Original policy |
| 62282 | Injection/Infusion Neurolytic Substance; Epidural, Lumbar/Caudal | Colorado Prior Authorization List, Pg 69 Original policy |