Anthem Blue Cross Blue Shield of Colorado prior authorization, page 30
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 |
|---|---|---|
| 63103 | Vertebral Corpectomy, Lateral Extracavitary Approach w Decompression Spinal Cord/Nerve Rts; Thoracic/Lumbar, ea addl Seg | Colorado Prior Authorization List, Pg 73 Original policy |
| 63180 | Laminectomy and section of dentate ligaments, with or without dural graft, cervical; 1 or 2 segments | Colorado Prior Authorization List, Pg 73 Original policy |
| 63182 | Laminectomy and section of dentate ligaments, with or without dural graft, cervical; more than 2 segments | Colorado Prior Authorization List, Pg 73 Original policy |
| 63185 | Laminectomy with rhizotomy; 1 or 2 segments | Colorado Prior Authorization List, Pg 73 Original policy |
| 63190 | Laminectomy with rhizotomy; more than 2 segments | Colorado Prior Authorization List, Pg 73 Original policy |
| 63191 | Laminectomy W/Section, Spinal Accessory Nerve | Colorado Prior Authorization List, Pg 73 Original policy |
| 63194 | Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; cervical | Colorado Prior Authorization List, Pg 74 Original policy |
| 63196 | Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; cervical | Colorado Prior Authorization List, Pg 74 Original policy |
| 63198 | Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages within 14 days; cervical | Colorado Prior Authorization List, Pg 74 Original policy |
| 63200 | Laminectomy, W/Release, Tethered Spinal Cord, Lumbar | Colorado Prior Authorization List, Pg 74 Original policy |
| 63250 | Laminectomy, Excision/Occlusion, Avm, Spinal Cord; Cervical | Colorado Prior Authorization List, Pg 74 Original policy |
| 63252 | Laminectomy, Excision/Occlusion, Avm, Spinal Cord; Thoracolumbar | Colorado Prior Authorization List, Pg 74 Original policy |
| 63265 | Laminectomy, Excision, Non-Neoplastic Lesion, Extradural; Cervical | Colorado Prior Authorization List, Pg 74 Original policy |
| 63267 | Laminectomy, Excision, Non-Neoplastic Lesion, Extradural; Lumbar | Colorado Prior Authorization List, Pg 74 Original policy |
| 63270 | Laminectomy, Excision, Intraspinal Lesion Other Than Neoplasm, Intradural; Cervical | Colorado Prior Authorization List, Pg 74 Original policy |
| 63272 | Laminectomy, Excision, Intraspinal Lesion Other Than Neoplasm, Intradural; Lumbar | Colorado Prior Authorization List, Pg 74 Original policy |
| 63275 | Laminectomy, Bx/Excision, Intraspinal Neoplasm; Extradural, Cervical | Colorado Prior Authorization List, Pg 74 Original policy |
| 63277 | Laminectomy, Bx/Excision, Intraspinal Neoplasm; Extradural, Lumbar | Colorado Prior Authorization List, Pg 74 Original policy |
| 63280 | Laminectomy, Bx/Excision, Intraspinal Neoplasm; Intradural, Extramedullary, Cervical | Colorado Prior Authorization List, Pg 75 Original policy |
| 63282 | Laminectomy, Bx/Excision, Intraspinal Neoplasm; Intradural, Extramedullary, Lumbar | Colorado Prior Authorization List, Pg 75 Original policy |
| 63285 | Laminectomy, Bx/Excision, Intraspinal Neoplasm; Intradural, Intramedullary, Cervical | Colorado Prior Authorization List, Pg 75 Original policy |
| 63287 | Laminectomy, Bx/Excision, Intraspinal Neoplasm; Intradural, Intramedullary, Thoracolumbar | Colorado Prior Authorization List, Pg 75 Original policy |
| 63290 | Laminectomy, Bx/Excision, Intraspinal Neoplasm; Extradural-Intradural Lesion, Any Level | Colorado Prior Authorization List, Pg 75 Original policy |
| 63300 | Vertebral Corpectomy, 1 Segment; Extradural, Cervical | Colorado Prior Authorization List, Pg 75 Original policy |
| 63301 | Vertebral Corpectomy, 1 Segment; Extradural, Thoracic, Transthoracic Approach | Colorado Prior Authorization List, Pg 75 Original policy |
| 63302 | Vertebral Corpectomy, 1 Segment; Extradural, Thoracic, Thoracolumbar Approach | Colorado Prior Authorization List, Pg 75 Original policy |
| 63303 | Vertebral Corpectomy, 1 Segment; Extradural, Lumbar/Sacral, Transperitoneal/Retroperitoneal Approach | Colorado Prior Authorization List, Pg 75 Original policy |
| 63304 | Vertebral Corpectomy, 1 Segment; Intradural, Cervical | Colorado Prior Authorization List, Pg 75 Original policy |
| 63305 | Vertebral Corpectomy, 1 Segment; Intradural, Thoracic, Transthoracic Approach | Colorado Prior Authorization List, Pg 75 Original policy |
| 63306 | Vertebral Corpectomy, 1 Segment; Intradural, Thoracic, Thoracolumbar Approach | Colorado Prior Authorization List, Pg 75 Original policy |
| 63307 | Vertebral Corpectomy, 1 Segment; Intradural, Lumbar/Sacral, Transperitoneal/Retroperitoneal Approach | Colorado Prior Authorization List, Pg 75 Original policy |
| 63308 | Vertebral Corpectomy, Add'l Segment | Colorado Prior Authorization List, Pg 75 Original policy |
| 63620 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion | Colorado Prior Authorization List, Pg 75 Original policy |
| 63650 | Percutaneous Implantation, Neurostimulator Electrode Array, Epidural | Colorado Prior Authorization List, Pg 75 Original policy |
| 63655 | Laminectomy, Implantation, Neurostimulator Electrodes, Plate/Paddle, Epidural | Colorado Prior Authorization List, Pg 75 Original policy |
| 63663 | Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including flu | Colorado Prior Authorization List, Pg 76 Original policy |
| 63664 | Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotom | Colorado Prior Authorization List, Pg 76 Original policy |
| 63685 | Insertion or replacement of spinal neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receive | Colorado Prior Authorization List, Pg 76 Original policy |
| 63688 | Revision or removal of implanted spinal neurostimulator pulse generator or receiver, with detachable connection to electrode array | Colorado Prior Authorization List, Pg 76 Original policy |
| 64405 | Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve | Colorado Prior Authorization List, Pg 76 Original policy |
| 64415 | Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed | Colorado Prior Authorization List, Pg 76 Original policy |
| 64417 | Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance, when performed | Colorado Prior Authorization List, Pg 76 Original policy |
| 64447 | Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance, when performed | Colorado Prior Authorization List, Pg 76 Original policy |
| 64450 | Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch | Colorado Prior Authorization List, Pg 76 Original policy |
| 64454 | Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed | Colorado Prior Authorization List, Pg 76 Original policy |
| 64479 | Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level | Colorado Prior Authorization List, Pg 76 Original policy |
| 64480 | Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (List separat | Colorado Prior Authorization List, Pg 76 Original policy |
| 64483 | Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level | Colorado Prior Authorization List, Pg 76 Original policy |
| 64484 | Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately | Colorado Prior Authorization List, Pg 76 Original policy |
| 64490 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Colorado Prior Authorization List, Pg 76 Original policy |