Anthem Blue Cross Blue Shield of Colorado prior authorization, page 31
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 |
|---|---|---|
| 64491 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Colorado Prior Authorization List, Pg 76 Original policy |
| 64492 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Colorado Prior Authorization List, Pg 76 Original policy |
| 64493 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Colorado Prior Authorization List, Pg 76 Original policy |
| 64494 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Colorado Prior Authorization List, Pg 77 Original policy |
| 64495 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Colorado Prior Authorization List, Pg 77 Original policy |
| 64505 | Injection, Anesthetic Agent; Sphenopalatine Ganglion | Colorado Prior Authorization List, Pg 77 Original policy |
| 64510 | Injection, Anesthetic Agent; Stellate Ganglion (Cervical Sympathetic) | Colorado Prior Authorization List, Pg 77 Original policy |
| 64520 | Injection, Anesthetic Agent; Lumbar/Thoracic (Paravertebral Sympathetic) | Colorado Prior Authorization List, Pg 77 Original policy |
| 64553 | Percutaneous implantation of neurostimulator electrode array; cranial nerve | Colorado Prior Authorization List, Pg 77 Original policy |
| 64555 | Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) | Colorado Prior Authorization List, Pg 77 Original policy |
| 64561 | Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed | Colorado Prior Authorization List, Pg 77 Original policy |
| 64566 | Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming | Colorado Prior Authorization List, Pg 77 Original policy |
| 64568 | Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator | Colorado Prior Authorization List, Pg 77 Original policy |
| 64569 | Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator | Colorado Prior Authorization List, Pg 77 Original policy |
| 64575 | Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) | Colorado Prior Authorization List, Pg 77 Original policy |
| 64581 | Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) | Colorado Prior Authorization List, Pg 77 Original policy |
| 64582 | Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array | Colorado Prior Authorization List, Pg 77 Original policy |
| 64585 | Revision or removal of peripheral neurostimulator electrode array | Colorado Prior Authorization List, Pg 77 Original policy |
| 64590 | Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pu | Colorado Prior Authorization List, Pg 77 Original policy |
| 64596 | Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode arra | Colorado Prior Authorization List, Pg 77 Original policy |
| 64600 | Destruction, Neurolytic, Trigeminal Nerve; Supraorbital/Infraorbital/Mental/Inferior Alveolar | Colorado Prior Authorization List, Pg 77 Original policy |
| 64605 | Destruction, Neurolytic, Trigeminal Nerve; 2nd & 3rd Division | Colorado Prior Authorization List, Pg 78 Original policy |
| 64610 | Destruction, Neurolytic, Trigeminal Nerve; 2nd & 3rd Division W/Radiologic Monitoring | Colorado Prior Authorization List, Pg 78 Original policy |
| 64624 | Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed | Colorado Prior Authorization List, Pg 78 Original policy |
| 64625 | Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) | Colorado Prior Authorization List, Pg 78 Original policy |
| 64628 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral | Colorado Prior Authorization List, Pg 78 Original policy |
| 64629 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to code | Colorado Prior Authorization List, Pg 78 Original policy |
| 64633 | Destruction By Neurolytic Agent, Paravertebral Facet Joint Nerve(S), With Imaging Guidance (Fluoroscopy Or Ct); Cervical Or Thoracic, Single Facet Joint | Colorado Prior Authorization List, Pg 78 Original policy |
| 64634 | Destruction By Neurolytic Agent, Paravertebral Facet Joint Nerve(S), With Imaging Guidance (Fluoroscopy Or Ct); Cervical Or Thoracic, Each Additional Facet Joint (List Separat | Colorado Prior Authorization List, Pg 78 Original policy |
| 64635 | Destruction By Neurolytic Agent, Paravertebral Facet Joint Nerve(S), With Imaging Guidance (Fluoroscopy Or Ct); Lumbar Or Sacral, Single Facet Joint | Colorado Prior Authorization List, Pg 78 Original policy |
| 64636 | Destruction By Neurolytic Agent, Paravertebral Facet Joint Nerve(S), With Imaging Guidance (Fluoroscopy Or Ct); Lumbar Or Sacral, Each Additional Facet Joint (List Separately | Colorado Prior Authorization List, Pg 78 Original policy |
| 64640 | Destruction, Neurolytic; Other Peripheral Nerve/Branch | Colorado Prior Authorization List, Pg 78 Original policy |
| 64716 | Neuroplasty &/Or Transposition; Cranial Nerve (Specify) | Colorado Prior Authorization List, Pg 78 Original policy |
| 64722 | Decompression; Unspecified Nerve(S) (Specify) | Colorado Prior Authorization List, Pg 78 Original policy |
| 64732 | Transection/Avulsion; Supraorbital Nerve | Colorado Prior Authorization List, Pg 78 Original policy |
| 64734 | Transection/Avulsion; Infraorbital Nerve | Colorado Prior Authorization List, Pg 78 Original policy |
| 64736 | Transection/Avulsion; Mental Nerve | Colorado Prior Authorization List, Pg 78 Original policy |
| 64738 | Transection/Avulsion; Inferior Alveolar Nerve, Osteotomy | Colorado Prior Authorization List, Pg 78 Original policy |
| 64740 | Transection/Avulsion; Lingual Nerve | Colorado Prior Authorization List, Pg 78 Original policy |
| 64742 | Transection/Avulsion; Facial Nerve, Differential/Complete | Colorado Prior Authorization List, Pg 78 Original policy |
| 64744 | Transection/Avulsion; Greater Occipital Nerve | Colorado Prior Authorization List, Pg 78 Original policy |
| 64771 | Transection/Avulsion, Other Cranial Nerve, Extradural | Colorado Prior Authorization List, Pg 78 Original policy |
| 64772 | Transection/Avulsion, Other Spinal Nerve, Extradural | Colorado Prior Authorization List, Pg 78 Original policy |
| 64776 | Excision of neuroma; digital nerve, 1 or both, same digit | Colorado Prior Authorization List, Pg 78 Original policy |
| 64782 | Excision, Neuroma; Hand/Foot, Except Digital Nerve | Colorado Prior Authorization List, Pg 78 Original policy |
| 64784 | Excision, Neuroma; Major Peripheral Nerve, Except Sciatic | Colorado Prior Authorization List, Pg 78 Original policy |
| 64788 | Excision, Neurofibroma/Neurolemmoma; Cutaneous Nerve | Colorado Prior Authorization List, Pg 79 Original policy |
| 64864 | Suture, Facial Nerve; Extracranial | Colorado Prior Authorization List, Pg 79 Original policy |
| 64865 | Suture, Facial Nerve; Infratemporal, W/Wo Grafting | Colorado Prior Authorization List, Pg 79 Original policy |
| 64866 | Anastomosis; Facial-Spinal Accessory | Colorado Prior Authorization List, Pg 79 Original policy |