Anthem Blue Cross Blue Shield of Colorado prior authorization, page 60
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 |
|---|---|---|
| 0952T | Totally implantable active middle ear hearing implant; revision or replacement, with mastoidectomy and replacement of sound processor | Colorado Prior Authorization List, Pg 141 Original policy |
| 0953T | Totally implantable active middle ear hearing implant; revision or replacement, without mastoidectomy and replacement of sound processor | Colorado Prior Authorization List, Pg 141 Original policy |
| 0954T | Totally implantable active middle ear hearing implant; replacement of sound processor only, with attachment to existing transducers | Colorado Prior Authorization List, Pg 141 Original policy |
| 0955T | Totally implantable active middle ear hearing implant; removal, including removal of sound processor and all implant components | Colorado Prior Authorization List, Pg 141 Original policy |
| 0964T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; single arch, without mandibular advancement mecha | Colorado Prior Authorization List, Pg 141 Original policy |
| 0965T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; dual arch, with additional mandibular advancement | Colorado Prior Authorization List, Pg 141 Original policy |
| 0966T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; dual arch, with additional mandibular advancement | Colorado Prior Authorization List, Pg 142 Original policy |
| 0970T | Ablation, benign breast tumor (eg, fibroadenoma), percutaneous, laser, including imaging guidance when performed, each tumor | Colorado Prior Authorization List, Pg 142 Original policy |
| 0971T | Ablation, malignant breast tumor(s), percutaneous, laser, including imaging guidance when performed, unilateral | Colorado Prior Authorization List, Pg 142 Original policy |
| 0978T | Submucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil | Colorado Prior Authorization List, Pg 142 Original policy |
| 0979T | Submucosal cryolysis therapy; soft palate only | Colorado Prior Authorization List, Pg 142 Original policy |
| 0980T | Submucosal cryolysis therapy; base of tongue and lingual tonsil only | Colorado Prior Authorization List, Pg 142 Original policy |
| A0430 | Fixed Wing Air Transport | Colorado Prior Authorization List, Pg 142 Original policy |
| A0431 | Rotary Wing Air Transport | Colorado Prior Authorization List, Pg 142 Original policy |
| A0435 | Fixed Wing Air Mileage | Colorado Prior Authorization List, Pg 142 Original policy |
| A0436 | Rotary Wing Air Mileage | Colorado Prior Authorization List, Pg 142 Original policy |
| A0888 | Noncovered Ambulance Mileage | Colorado Prior Authorization List, Pg 142 Original policy |
| A2001 | Innovamatrix ac, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2002 | Mirragen advanced wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2004 | Xcellistem, 1 mg/Original description: Miscellaneous with Motor <27.85, without comorbidities,10/2019 description: Miscellaneous M <46.50 and A >=77.50.,witho | Colorado Prior Authorization List, Pg 142 Original policy |
| A2005 | Microlyte matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2006 | Novosorb synpath dermal matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2007 | Restrata, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2008 | Theragenesis, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2009 | Symphony, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2010 | Apis, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2011 | Supra sdrm, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2012 | Suprathel, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2013 | Innovamatrix fs, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2014 | Omeza collagen matrix or omeza complete matrix, per 100 mg | Colorado Prior Authorization List, Pg 142 Original policy |
| A2015 | Phoenix wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2016 | Permeaderm b, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2017 | PermeaDerm Glove, each | Colorado Prior Authorization List, Pg 142 Original policy |
| A2018 | Permeaderm c, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2019 | Kerecis omega3 marigen shield, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2020 | Ac5 advanced wound system (ac5) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2021 | Neomatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2022 | Innovaburn or innovamatrix xl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2023 | InnovaMatrix PD, 1 mg | Colorado Prior Authorization List, Pg 142 Original policy |
| A2024 | Resolve matrix or xenopatch, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2025 | Miro3d, per cubic centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 142 Original policy |
| A2026 | Restrata MiniMatrix, 5 mg | Colorado Prior Authorization List, Pg 143 Original policy |
| A2027 | Matriderm, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 143 Original policy |
| A2028 | Micromatrix flex, per mg | Colorado Prior Authorization List, Pg 143 Original policy |
| A2029 | Mirotract wound matrix sheet, per cubic centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 143 Original policy |
| A2030 | Miro3D fibers, per mg | Colorado Prior Authorization List, Pg 143 Original policy |
| A2031 | Mirodry wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 143 Original policy |
| A2032 | Myriad matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 143 Original policy |
| A2033 | Myriad Morcells, 4 mg | Colorado Prior Authorization List, Pg 143 Original policy |
| A2034 | Foundation drs solo, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 143 Original policy |