Anthem Blue Cross Blue Shield of Colorado prior authorization, page 6
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 |
|---|---|---|
| 21087 | Impression & Custom Preparation; Nasal Prosthesis | Colorado Prior Authorization List, Pg 13 Original policy |
| 21110 | Application, Interdental Fixation Device, Non-Fx/Dislocation, W/Removal | Colorado Prior Authorization List, Pg 13 Original policy |
| 21116 | Injection Proc, Temporomandibular Joint Arthrography | Colorado Prior Authorization List, Pg 13 Original policy |
| 21120 | Genioplasty; Augmentation (Autograft, Allograft, Prosthetic Matl) | Colorado Prior Authorization List, Pg 13 Original policy |
| 21121 | Genioplasty; Sliding Osteotomy, Single Piece | Colorado Prior Authorization List, Pg 13 Original policy |
| 21122 | Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin | Colorado Prior Authorization List, Pg 13 Original policy |
| 21123 | Genioplasty; Sliding, Augmentation W/Interpositional Bone Grafts W/Obtaining Autograft | Colorado Prior Authorization List, Pg 13 Original policy |
| 21125 | Augmentation, Mandibular Body/Angle; Prosthetic Matl | Colorado Prior Authorization List, Pg 13 Original policy |
| 21127 | Augmentation, Mandibular Body/Angle; W/Bone Graft/Onlay/Interpositional W/Obtaining Autograft | Colorado Prior Authorization List, Pg 13 Original policy |
| 21137 | Reduction Forehead; Contouring Only | Colorado Prior Authorization List, Pg 13 Original policy |
| 21138 | Reduction Forehead; Contouring/Prosthesis/Bone Graft W/Obtaining Autograft | Colorado Prior Authorization List, Pg 13 Original policy |
| 21139 | Reduction Forehead; Contouring & Setback, Anterior Frontal Sinus Wall | Colorado Prior Authorization List, Pg 13 Original policy |
| 21141 | Reconstruction Midface, Lefort I; 1 Piece, W/O Bone Graft | Colorado Prior Authorization List, Pg 14 Original policy |
| 21142 | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft | Colorado Prior Authorization List, Pg 14 Original policy |
| 21143 | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft | Colorado Prior Authorization List, Pg 14 Original policy |
| 21145 | Reconstruction Midface, Lefort I; 1 Piece, W/Bone Grafts | Colorado Prior Authorization List, Pg 14 Original policy |
| 21146 | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining | Colorado Prior Authorization List, Pg 14 Original policy |
| 21147 | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes o | Colorado Prior Authorization List, Pg 14 Original policy |
| 21150 | Reconstruction Midface, Lefort Ii; Anterior Intrusion | Colorado Prior Authorization List, Pg 14 Original policy |
| 21151 | Reconstruction Midface, Lefort Ii; W/Bone Grafts | Colorado Prior Authorization List, Pg 14 Original policy |
| 21154 | Reconstruction Midface, Lefort Iii, W/Bone Grafts; W/O Lefort I | Colorado Prior Authorization List, Pg 14 Original policy |
| 21155 | Reconstruction Midface, Lefort Iii, W/Bone Grafts; W/Lefort I | Colorado Prior Authorization List, Pg 14 Original policy |
| 21159 | Reconstruction Midface, Lefort Iii, (Extra/Intracranial), W/Bone Grafts, W/O Lefort I | Colorado Prior Authorization List, Pg 14 Original policy |
| 21160 | Reconstruction Midface, Lefort Iii, (Extra/Intracranial), W/Bone Grafts, W/Lefort I | Colorado Prior Authorization List, Pg 14 Original policy |
| 21172 | Reconstruction Superior-Lateral Orbital Rim & Lower Forehead | Colorado Prior Authorization List, Pg 14 Original policy |
| 21175 | Reconstruction, Bifrontal,Superior-Lateral Orbital Rims & Lower Forehead | Colorado Prior Authorization List, Pg 14 Original policy |
| 21179 | Reconstruction, Majority, Forehead & Supraorbital Rims; W/Grafts (Allograft/Prosthetic) | Colorado Prior Authorization List, Pg 14 Original policy |
| 21180 | Reconstruction, Majority, Forehead & Supraorbital Rims; W/Autograft | Colorado Prior Authorization List, Pg 14 Original policy |
| 21182 | Reconstruction, Orbit/Forehead/Nasoethmoid, Following Excision, Benign Tumor, Graft < 40 Sq Cm | Colorado Prior Authorization List, Pg 14 Original policy |
| 21183 | Reconstruction, Orbit/Forehead/Nasoethmiod, Following Excision, Benign Tumor, Graft 40-80 Sq Cm | Colorado Prior Authorization List, Pg 14 Original policy |
| 21184 | Reconstruction, Orbit/Forehead/Nasoethmoid, Following Excision, Benign Tumor, Graft > 80 Sq Cm | Colorado Prior Authorization List, Pg 14 Original policy |
| 21188 | Reconstruction, Midface, Osteotomies (Non-Lefort Type), W/Grafts, W/Obtaining Autografts | Colorado Prior Authorization List, Pg 14 Original policy |
| 21193 | Reconstruction, Mandibular Rami, Horizontal, Vertical, "C"/"L" Osteotomy; W/O Bone Graft | Colorado Prior Authorization List, Pg 15 Original policy |
| 21194 | Reconstruction, Mandibular Rami, Horizontal, Vertical, "C"/"L" Osteotomy; W/Bone Graft | Colorado Prior Authorization List, Pg 15 Original policy |
| 21195 | Reconstruction, Mandibular Rami &/Or Body, Sagittal Split; W/O Int Rigid Fixation | Colorado Prior Authorization List, Pg 15 Original policy |
| 21196 | Reconstruction, Mandibular Rami &/Or Body, Sagittal Split; W/Int Rigid Fixation | Colorado Prior Authorization List, Pg 15 Original policy |
| 21198 | Osteotomy, Mandible, Segmental | Colorado Prior Authorization List, Pg 15 Original policy |
| 21199 | Osteotomy, Mandible, Segmental; W/Genioglossus Advancement | Colorado Prior Authorization List, Pg 15 Original policy |
| 21206 | Osteotomy, Maxilla, Segmental | Colorado Prior Authorization List, Pg 15 Original policy |
| 21208 | Osteoplasty, Facial Bones; Augmentation (Autograft, Allograft/Prosthetic Implant) | Colorado Prior Authorization List, Pg 15 Original policy |
| 21209 | Osteoplasty, Facial Bones; Reduction | Colorado Prior Authorization List, Pg 15 Original policy |
| 21210 | Graft, Bone; Nasal, Maxillary/Malar Areas (Includes Obtaining Graft) | Colorado Prior Authorization List, Pg 15 Original policy |
| 21215 | Graft, Bone; Mandible (Includes Obtaining Graft) | Colorado Prior Authorization List, Pg 15 Original policy |
| 21230 | Graft; Rib Cartilage, Autogenous, Face/Chin/Nose/Ear (Includes Obtaining Graft) | Colorado Prior Authorization List, Pg 15 Original policy |
| 21235 | Graft; Ear Cartilage, Autogenous, Nose/Ear (Includes Obtaining Graft) | Colorado Prior Authorization List, Pg 15 Original policy |
| 21240 | Arthroplasty, Temporomandibular Joint, W/Wo Autograft (Includes Obtaining Graft) | Colorado Prior Authorization List, Pg 15 Original policy |
| 21242 | Arthroplasty, Temporomandibular Joint, W/Allograft | Colorado Prior Authorization List, Pg 15 Original policy |
| 21243 | Arthroplasty, Temporomandibular Joint, W/Prosthetic Joint Replacement | Colorado Prior Authorization List, Pg 15 Original policy |
| 21244 | Reconstruction, Mandible, Extraoral, W/Transosteal Bone Plate | Colorado Prior Authorization List, Pg 15 Original policy |
| 21245 | Reconstruction, Mandible/Maxilla, Subperiosteal Implant; Partial | Colorado Prior Authorization List, Pg 15 Original policy |