Anthem Blue Cross Blue Shield of Colorado prior authorization, page 61
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 |
|---|---|---|
| A2035 | Corplex P or Theracor P or Allacor P, per mg | Colorado Prior Authorization List, Pg 143 Original policy |
| A4100 | Non-sheet form skin substitute, fda cleared as a device, not otherwise specified (list in addition to primary procedure) | Colorado Prior Authorization List, Pg 143 Original policy |
| A4341 | Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each | Colorado Prior Authorization List, Pg 143 Original policy |
| A4342 | Accessories for patient inserted indwelling intraurethral drainage device with valve, replacement only, each | Colorado Prior Authorization List, Pg 143 Original policy |
| A4438 | Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each | Colorado Prior Authorization List, Pg 143 Original policy |
| A4468 | Exsufflation belt, includes all supplies and accessories | Colorado Prior Authorization List, Pg 143 Original policy |
| A4540 | Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm | Colorado Prior Authorization List, Pg 143 Original policy |
| A4542 | Supplies and accessories for external upper limb tremor stimulator of the peripheral nerves of the wrist | Colorado Prior Authorization List, Pg 143 Original policy |
| A4543 | Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month | Colorado Prior Authorization List, Pg 143 Original policy |
| A4544 | Electrode for external lower extremity nerve stimulator for restless legs syndrome | Colorado Prior Authorization List, Pg 143 Original policy |
| A4545 | Supplies and accessories for external tibial nerve stimulator (e.g., socks, gel pads, electrodes, etc.), needed for one month | Colorado Prior Authorization List, Pg 143 Original policy |
| A4575 | Hyperbaric O2 Chamber Disps | Colorado Prior Authorization List, Pg 143 Original policy |
| A4596 | Cranial electrotherapy stimulation (ces) system supplies and accessories, per month | Colorado Prior Authorization List, Pg 143 Original policy |
| A4600 | SLEEVE FOR INTERMITTENT LIMB COMPRESSION DEVICE, REPLACEMENT ONLY, EACH | Colorado Prior Authorization List, Pg 143 Original policy |
| A4604 | Tubing with integrated heating element for use with positive airway pressure device | Colorado Prior Authorization List, Pg 143 Original policy |
| A7027 | Combination oral/nasal mask, used with continuous positive airway pressure | Colorado Prior Authorization List, Pg 143 Original policy |
| A7028 | Oral cushion for combination oral/nasal mask, replacement only, each | Colorado Prior Authorization List, Pg 143 Original policy |
| A7029 | Nasal pillows for combination oral/nasal mask, replacement only, pair | Colorado Prior Authorization List, Pg 143 Original policy |
| A7030 | Full Face Mask Used With Positive Airway Pressure Device, Each | Colorado Prior Authorization List, Pg 143 Original policy |
| A7031 | Face Mask Interface, Replacement For Full Face Mask, Each | Colorado Prior Authorization List, Pg 143 Original policy |
| A7032 | Cushion for use on nasal mask interface, replacement only, each | Colorado Prior Authorization List, Pg 143 Original policy |
| A7033 | Pillow for use on nasal cannula type interface, replacement only, pair | Colorado Prior Authorization List, Pg 143 Original policy |
| A7034 | Nasal Interface (Mask Or Cannula Type) Used With Positive Airway Press | Colorado Prior Authorization List, Pg 143 Original policy |
| A7035 | Headgear Used With Positive Airway Pressure Device | Colorado Prior Authorization List, Pg 143 Original policy |
| A7036 | Chinstrap Used With Positive Airway Pressure Device | Colorado Prior Authorization List, Pg 143 Original policy |
| A7037 | Tubing Used With Positive Airway Pressure Device | Colorado Prior Authorization List, Pg 143 Original policy |
| A7038 | Filter, Disposable, Used With Positive Airway Pressure Device | Colorado Prior Authorization List, Pg 144 Original policy |
| A7039 | Filter, Non Disposable, Used With Positive Airway Pressure Device | Colorado Prior Authorization List, Pg 144 Original policy |
| A7044 | Oral Interface Used With Positive Airway Pressure Device, Each | Colorado Prior Authorization List, Pg 144 Original policy |
| A7045 | Repl exhalation port for PAP | Colorado Prior Authorization List, Pg 144 Original policy |
| A7046 | Water chamber for humidifier, used with positive airway pressure device, replacement, each | Colorado Prior Authorization List, Pg 144 Original policy |
| A9268 | Programmer for transient, orally ingested capsule | Colorado Prior Authorization List, Pg 144 Original policy |
| A9269 | Programmable, transient, orally ingested capsule, for use with external programmer, per month | Colorado Prior Authorization List, Pg 144 Original policy |
| A9513 | Lutetium Lu 177, dotatate, therapeutic, 1 mCi | Colorado Prior Authorization List, Pg 144 Original policy |
| A9543 | Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries | Colorado Prior Authorization List, Pg 144 Original policy |
| A9606 | Radium RA-223 dichloride, therapeutic, per UCI | Colorado Prior Authorization List, Pg 144 Original policy |
| A9607 | Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie | Colorado Prior Authorization List, Pg 144 Original policy |
| B4164 | Parenteral 50% Dextrose Solu | Colorado Prior Authorization List, Pg 144 Original policy |
| B4168 | Parenteral Sol Amino Acid 3. | Colorado Prior Authorization List, Pg 144 Original policy |
| B4172 | Parenteral Sol Amino Acid 5. | Colorado Prior Authorization List, Pg 144 Original policy |
| B4176 | Parenteral Sol Amino Acid 7 | Colorado Prior Authorization List, Pg 144 Original policy |
| B4178 | Parenteral Sol Amino Acid > | Colorado Prior Authorization List, Pg 144 Original policy |
| B4180 | Parenteral Sol Carb > 50% | Colorado Prior Authorization List, Pg 144 Original policy |
| B4185 | Parenteral nutrition solution, not otherwise specified, 10 grams lipids | Colorado Prior Authorization List, Pg 144 Original policy |
| B4187 | Omegaven, 10 g lipids | Colorado Prior Authorization List, Pg 144 Original policy |
| B4189 | Parenteral Sol Amino Acid & | Colorado Prior Authorization List, Pg 144 Original policy |
| B4193 | Parenteral Sol 52-73 Gm Prot | Colorado Prior Authorization List, Pg 144 Original policy |
| B4197 | Parenteral Sol 74-100 Gm Pro | Colorado Prior Authorization List, Pg 144 Original policy |
| B4199 | Parenteral Sol > 100gm Prote | Colorado Prior Authorization List, Pg 144 Original policy |
| B4216 | Parenteral Nutrition Additiv | Colorado Prior Authorization List, Pg 144 Original policy |