Anthem Blue Cross Blue Shield of Colorado prior authorization, page 58
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 |
|---|---|---|
| 0636T | Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s) | Colorado Prior Authorization List, Pg 137 Original policy |
| 0637T | Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s) | Colorado Prior Authorization List, Pg 137 Original policy |
| 0638T | Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s) | Colorado Prior Authorization List, Pg 137 Original policy |
| 0646T | Transcatheter tricuspid valve implantation/replacement (TTVI) with pro | Colorado Prior Authorization List, Pg 137 Original policy |
| 0648T | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmissio | Colorado Prior Authorization List, Pg 137 Original policy |
| 0652T | Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, includin | Colorado Prior Authorization List, Pg 137 Original policy |
| 0653T | Esophagogastroduodenoscopy, flexible, transnasal; with biopsy, single | Colorado Prior Authorization List, Pg 137 Original policy |
| 0654T | Esophagogastroduodenoscopy, flexible, transnasal; with insertion of in | Colorado Prior Authorization List, Pg 137 Original policy |
| 0655T | Transperineal focal laser ablation of malignant prostate tissue, inclu | Colorado Prior Authorization List, Pg 137 Original policy |
| 0658T | Electrical impedance spectroscopy of 1 or more skin lesions for automa | Colorado Prior Authorization List, Pg 137 Original policy |
| 0659T | Transcatheter intracoronary infusion of supersaturated oxygen in conju | Colorado Prior Authorization List, Pg 137 Original policy |
| 0664T | Donor hysterectomy (including cold preservation); open, from cadaver d | Colorado Prior Authorization List, Pg 137 Original policy |
| 0665T | Donor hysterectomy (including cold preservation); open, from living do | Colorado Prior Authorization List, Pg 137 Original policy |
| 0666T | Donor hysterectomy (including cold preservation); laparoscopic or robo | Colorado Prior Authorization List, Pg 137 Original policy |
| 0667T | Donor hysterectomy (including cold preservation); recipient uterus all | Colorado Prior Authorization List, Pg 137 Original policy |
| 0668T | Backbench standard preparation of cadaver or living donor uterine allo | Colorado Prior Authorization List, Pg 137 Original policy |
| 0669T | Backbench reconstruction of cadaver or living donor uterus allograft p | Colorado Prior Authorization List, Pg 137 Original policy |
| 0670T | Backbench reconstruction of cadaver or living donor uterus allograft p | Colorado Prior Authorization List, Pg 137 Original policy |
| 0671T | Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more | Colorado Prior Authorization List, Pg 138 Original policy |
| 0672T | Endovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence | Colorado Prior Authorization List, Pg 138 Original policy |
| 0673T | Ablation, benign thyroid nodule(s), percutaneous, laser, including imaging guidance | Colorado Prior Authorization List, Pg 138 Original policy |
| 0686T | Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance | Colorado Prior Authorization List, Pg 138 Original policy |
| 0689T | Quantitative ultrasound tissue characterization (non-elastographic), including interpretation and report, obtained without diagnostic ultrasound examination of the same anatom | Colorado Prior Authorization List, Pg 138 Original policy |
| 0692T | Therapeutic ultrafiltration | Colorado Prior Authorization List, Pg 138 Original policy |
| 0700T | Molecular fluorescent imaging of suspicious nevus; first lesion | Colorado Prior Authorization List, Pg 138 Original policy |
| 0701T | Molecular fluorescent imaging of suspicious nevus; each additional lesion (List separately in addition to code for primary procedure) | Colorado Prior Authorization List, Pg 138 Original policy |
| 0707T | Injection(s), bone-substitute material (eg, calcium phosphate) into subchondral bone defect (ie, bone marrow lesion, bone bruise, stress injury, microtrabecular fracture), inc | Colorado Prior Authorization List, Pg 138 Original policy |
| 0717T | Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, i | Colorado Prior Authorization List, Pg 138 Original policy |
| 0718T | Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilate | Colorado Prior Authorization List, Pg 138 Original policy |
| 0736T | Colonic lavage, 35 or more liters of water, gravity-fed, with induced defecation, including insertion of rectal catheter | Colorado Prior Authorization List, Pg 138 Original policy |
| 0738T | Treatment planning for magnetic field induction ablation of malignant prostate tissue, using data from previously performed magnetic resonance imaging (MRI) examination | Colorado Prior Authorization List, Pg 138 Original policy |
| 0739T | Ablation of malignant prostate tissue by magnetic field induction, including all intraprocedural, transperineal needle/catheter placement for nanoparticle installation and int | Colorado Prior Authorization List, Pg 138 Original policy |
| 0745T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image da | Colorado Prior Authorization List, Pg 138 Original policy |
| 0746T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiati | Colorado Prior Authorization List, Pg 138 Original policy |
| 0747T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia | Colorado Prior Authorization List, Pg 138 Original policy |
| 0748T | Injections of stem cell product into perianal perifistular soft tissue, including fistula preparation (eg, removal of setons, fistula curettage, closure of internal openings) | Colorado Prior Authorization List, Pg 138 Original policy |
| 0766T | Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, with identification and marking of the treatment location, including noni | Colorado Prior Authorization List, Pg 138 Original policy |
| 0767T | Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, with identification and marking of the treatment location, including noni | Colorado Prior Authorization List, Pg 138 Original policy |
| 0770T | Virtual reality technology to assist therapy (List separately in addition to code for primary procedure) | Colorado Prior Authorization List, Pg 138 Original policy |
| 0771T | Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic servi | Colorado Prior Authorization List, Pg 138 Original policy |
| 0772T | Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic servi | Colorado Prior Authorization List, Pg 138 Original policy |
| 0773T | Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health ca | Colorado Prior Authorization List, Pg 138 Original policy |
| 0774T | Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health ca | Colorado Prior Authorization List, Pg 139 Original policy |
| 0778T | Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscl | Colorado Prior Authorization List, Pg 139 Original policy |
| 0786T | Insertion or replacement of percutaneous electrode array, sacral, with integrated neurostimulator, including imaging guidance, when performed | Colorado Prior Authorization List, Pg 139 Original policy |
| 0787T | Revision or removal of neurostimulator electrode array, sacral, with integrated neurostimulator | Colorado Prior Authorization List, Pg 139 Original policy |
| 0795T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventric | Colorado Prior Authorization List, Pg 139 Original policy |
| 0796T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventric | Colorado Prior Authorization List, Pg 139 Original policy |
| 0797T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventric | Colorado Prior Authorization List, Pg 139 Original policy |
| 0798T | Transcatheter removal of permanent dual-chamber leadless pacemaker,?including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventricul | Colorado Prior Authorization List, Pg 139 Original policy |