Anthem Blue Cross Blue Shield of Colorado prior authorization, page 4
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 |
|---|---|---|
| 15829 | Rhytidectomy; Superficial Musculoaponeurotic System (Smas) Flap | Colorado Prior Authorization List, Pg 8 Original policy |
| 15830 | Excision, excessive skin and subcutaneous tissue (incluedes lipectomy, abdomen, infraumbilical panniculectomy | Colorado Prior Authorization List, Pg 8 Original policy |
| 15832 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh | Colorado Prior Authorization List, Pg 8 Original policy |
| 15833 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg | Colorado Prior Authorization List, Pg 8 Original policy |
| 15834 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip | Colorado Prior Authorization List, Pg 8 Original policy |
| 15835 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock | Colorado Prior Authorization List, Pg 8 Original policy |
| 15836 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm | Colorado Prior Authorization List, Pg 8 Original policy |
| 15837 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand | Colorado Prior Authorization List, Pg 8 Original policy |
| 15838 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad | Colorado Prior Authorization List, Pg 8 Original policy |
| 15839 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area | Colorado Prior Authorization List, Pg 8 Original policy |
| 15840 | Graft, Facial Nerve Paralysis; Free Fascia Graft (W/Obtaining Fascia) | Colorado Prior Authorization List, Pg 8 Original policy |
| 15841 | Graft, Facial Nerve Paralysis; Free Muscle Graft (W/Obtaining Graft) | Colorado Prior Authorization List, Pg 8 Original policy |
| 15842 | Graft, Facial Nerve Paralysis; Free Muscle Flap, Microsurgical Technique | Colorado Prior Authorization List, Pg 8 Original policy |
| 15845 | Graft, Facial Nerve Paralysis; Regional Muscle Transfer | Colorado Prior Authorization List, Pg 8 Original policy |
| 15876 | Suction Assisted Lipectomy; Head & Neck | Colorado Prior Authorization List, Pg 8 Original policy |
| 15877 | Suction Assisted Lipectomy; Trunk | Colorado Prior Authorization List, Pg 9 Original policy |
| 15878 | Suction Assisted Lipectomy; Upper Extremity | Colorado Prior Authorization List, Pg 9 Original policy |
| 15879 | Suction Assisted Lipectomy; Lower Extremity | Colorado Prior Authorization List, Pg 9 Original policy |
| 17000 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions ( | Colorado Prior Authorization List, Pg 9 Original policy |
| 17004 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions ( | Colorado Prior Authorization List, Pg 9 Original policy |
| 17106 | Destruction, Cutaneous Vascular Proliferative Lesions; < 10 Sq Cm | Colorado Prior Authorization List, Pg 9 Original policy |
| 17107 | Destruction, Cutaneous Vascular Proliferative Lesions; 10.0-50.0 Sq Cm | Colorado Prior Authorization List, Pg 9 Original policy |
| 17108 | Destruction, Cutaneous Vascular Proliferative Lesions; > 50.0 Sq Cm | Colorado Prior Authorization List, Pg 9 Original policy |
| 17110 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions othe | Colorado Prior Authorization List, Pg 9 Original policy |
| 17111 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions othe | Colorado Prior Authorization List, Pg 9 Original policy |
| 17311 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, colo | Colorado Prior Authorization List, Pg 9 Original policy |
| 17313 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, colo | Colorado Prior Authorization List, Pg 9 Original policy |
| 17380 | Electrolysis epilation, each 30 minutes | Colorado Prior Authorization List, Pg 9 Original policy |
| 19105 | Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma | Colorado Prior Authorization List, Pg 9 Original policy |
| 19112 | Excision, Lactiferous Duct Fistula | Colorado Prior Authorization List, Pg 9 Original policy |
| 19140 | Mastectomy, Gynecomastia | Colorado Prior Authorization List, Pg 9 Original policy |
| 19296 | Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial rad | Colorado Prior Authorization List, Pg 9 Original policy |
| 19298 | Placement of radiotherapy after loading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the tim | Colorado Prior Authorization List, Pg 9 Original policy |
| 19300 | Mastectomy for gynecomastia | Colorado Prior Authorization List, Pg 9 Original policy |
| 19316 | Mastopexy | Colorado Prior Authorization List, Pg 9 Original policy |
| 19318 | Breast reduction | Colorado Prior Authorization List, Pg 9 Original policy |
| 19324 | Mammaplasty, augmentation; without prosthetic implant | Colorado Prior Authorization List, Pg 9 Original policy |
| 19325 | Breast augmentation with implant | Colorado Prior Authorization List, Pg 10 Original policy |
| 19328 | Removal of intact breast implant | Colorado Prior Authorization List, Pg 10 Original policy |
| 19330 | Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel) | Colorado Prior Authorization List, Pg 10 Original policy |
| 19340 | Insertion of breast implant on same day of mastectomy (ie, immediate) | Colorado Prior Authorization List, Pg 10 Original policy |
| 19342 | Insertion or replacement of breast implant on separate day from mastectomy | Colorado Prior Authorization List, Pg 10 Original policy |
| 19350 | Nipple/Areola Reconstruction | Colorado Prior Authorization List, Pg 10 Original policy |
| 19355 | Correction, Inverted Nipples | Colorado Prior Authorization List, Pg 10 Original policy |
| 19357 | Tissue expander placement in breast reconstruction, including subsequent expansion(s) | Colorado Prior Authorization List, Pg 10 Original policy |
| 19361 | Breast reconstruction; with latissimus dorsi flap | Colorado Prior Authorization List, Pg 10 Original policy |
| 19364 | Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap) | Colorado Prior Authorization List, Pg 10 Original policy |
| 19366 | Breast reconstruction with other technique | Colorado Prior Authorization List, Pg 10 Original policy |
| 19367 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap | Colorado Prior Authorization List, Pg 10 Original policy |
| 19368 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging) | Colorado Prior Authorization List, Pg 11 Original policy |