Anthem Blue Cross Blue Shield of Colorado prior authorization, page 38
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 |
|---|---|---|
| 75571 | Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium | Colorado Prior Authorization List, Pg 91 Original policy |
| 75572 | Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D ima | Colorado Prior Authorization List, Pg 91 Original policy |
| 75573 | Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postproce | Colorado Prior Authorization List, Pg 91 Original policy |
| 75574 | Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, inc | Colorado Prior Authorization List, Pg 91 Original policy |
| 75580 | Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of the data set from a coronary computed tomography angiography, wit | Colorado Prior Authorization List, Pg 91 Original policy |
| 75635 | Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast materi | Colorado Prior Authorization List, Pg 91 Original policy |
| 76120 | Cineradiography/Videoradiology, Except Where Specifically Included | Colorado Prior Authorization List, Pg 91 Original policy |
| 76376 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under co | Colorado Prior Authorization List, Pg 91 Original policy |
| 76377 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under co | Colorado Prior Authorization List, Pg 91 Original policy |
| 76390 | Mr Spectroscopy | Colorado Prior Authorization List, Pg 91 Original policy |
| 76391 | Magnetic resonance (eg, vibration) elastography | Colorado Prior Authorization List, Pg 91 Original policy |
| 76873 | Echography, Transrectal; Prostate Volume Study, Brachytherapy Planning | Colorado Prior Authorization List, Pg 91 Original policy |
| 76965 | Us Guided, Interstitial Radioelement Application | Colorado Prior Authorization List, Pg 91 Original policy |
| 77046 | Magnetic resonance imaging, breast, without contrast material; unilateral | Colorado Prior Authorization List, Pg 91 Original policy |
| 77047 | Magnetic resonance imaging, breast, without contrast material; bilateral | Colorado Prior Authorization List, Pg 91 Original policy |
| 77048 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokin | Colorado Prior Authorization List, Pg 91 Original policy |
| 77049 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokin | Colorado Prior Authorization List, Pg 91 Original policy |
| 77078 | Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) | Colorado Prior Authorization List, Pg 91 Original policy |
| 77083 | Radiographic absorptiometry (eg, photodensitometry, radiogrammetry), 1 or more sites | Colorado Prior Authorization List, Pg 91 Original policy |
| 77084 | Magnetic resonance (eg, proton) imaging, bone marrow blood supply | Colorado Prior Authorization List, Pg 91 Original policy |
| 77295 | 3-dimensional radiotherapy plan, including dose-volume histograms | Colorado Prior Authorization List, Pg 91 Original policy |
| 77301 | Intensity Modulated Radiotherapy Plan W/Dose Volume Histograms | Colorado Prior Authorization List, Pg 91 Original policy |
| 77316 | Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s) | Colorado Prior Authorization List, Pg 91 Original policy |
| 77317 | Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation( | Colorado Prior Authorization List, Pg 92 Original policy |
| 77318 | Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) | Colorado Prior Authorization List, Pg 92 Original policy |
| 77338 | Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT | Colorado Prior Authorization List, Pg 92 Original policy |
| 77370 | Special Medical Radiation Physics Consultation | Colorado Prior Authorization List, Pg 92 Original policy |
| 77371 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consist | Colorado Prior Authorization List, Pg 92 Original policy |
| 77372 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consist | Colorado Prior Authorization List, Pg 92 Original policy |
| 77373 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, en | Colorado Prior Authorization List, Pg 92 Original policy |
| 77387 | Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed | Colorado Prior Authorization List, Pg 92 Original policy |
| 77402 | Radiation treatment delivery; Level 1 (eg, single-electron field, multiple-electron fields, or 2D photons), including imaging guidance, when performed | Colorado Prior Authorization List, Pg 92 Original policy |
| 77407 | Radiation treatment delivery; Level 2, single-isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed | Colorado Prior Authorization List, Pg 92 Original policy |
| 77412 | Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (eg, 2D, 3D, or IMRT) or a single-isocenter photon therapy (eg, 3D or IMRT) with active motion m | Colorado Prior Authorization List, Pg 92 Original policy |
| 77423 | High energy neutron radiation treatment delivery, 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) | Colorado Prior Authorization List, Pg 92 Original policy |
| 77424 | Intraoperative Radiation Treatment Delivery, X-Ray, Single Treatment Session | Colorado Prior Authorization List, Pg 92 Original policy |
| 77425 | Intraoperative Radiation Treatment Delivery, Electrons, Single Treatment Session | Colorado Prior Authorization List, Pg 92 Original policy |
| 77432 | Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) | Colorado Prior Authorization List, Pg 92 Original policy |
| 77435 | Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image g | Colorado Prior Authorization List, Pg 92 Original policy |
| 77469 | Intraoperative Radiation Treatment Management | Colorado Prior Authorization List, Pg 92 Original policy |
| 77470 | Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation) | Colorado Prior Authorization List, Pg 93 Original policy |
| 77520 | Proton Treatment Delivery; Simple W/O Compensation | Colorado Prior Authorization List, Pg 93 Original policy |
| 77522 | Proton Treatment Delivery; Simple W/Compensation | Colorado Prior Authorization List, Pg 93 Original policy |
| 77523 | Proton Treatment Delivery; Intermediate | Colorado Prior Authorization List, Pg 93 Original policy |
| 77525 | Proton Treatment Delivery; Complex | Colorado Prior Authorization List, Pg 93 Original policy |
| 77761 | Intracavitary Radiation Source Application; Simple | Colorado Prior Authorization List, Pg 93 Original policy |
| 77762 | Intracavitary Radiation Source Application; Intermediate | Colorado Prior Authorization List, Pg 93 Original policy |
| 77763 | Intracavitary Radiation Source Application; Complex | Colorado Prior Authorization List, Pg 93 Original policy |
| 77767 | Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel | Colorado Prior Authorization List, Pg 93 Original policy |
| 77768 | Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or mu | Colorado Prior Authorization List, Pg 93 Original policy |