Anthem Blue Cross Blue Shield of Colorado prior authorization, page 63
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 |
|---|---|---|
| C5271 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | Colorado Prior Authorization List, Pg 146 Original policy |
| C5272 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (lis | Colorado Prior Authorization List, Pg 146 Original policy |
| C5273 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of b | Colorado Prior Authorization List, Pg 146 Original policy |
| C5274 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area | Colorado Prior Authorization List, Pg 146 Original policy |
| C5275 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up t | Colorado Prior Authorization List, Pg 146 Original policy |
| C5276 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up t | Colorado Prior Authorization List, Pg 146 Original policy |
| C5277 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area grea | Colorado Prior Authorization List, Pg 146 Original policy |
| C5278 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area grea | Colorado Prior Authorization List, Pg 146 Original policy |
| C7513 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s) | Colorado Prior Authorization List, Pg 146 Original policy |
| C7514 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s) | Colorado Prior Authorization List, Pg 147 Original policy |
| C7515 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s) | Colorado Prior Authorization List, Pg 147 Original policy |
| C7517 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, with iliac and/or femoral artery angiograph | Colorado Prior Authorization List, Pg 147 Original policy |
| C7530 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s) | Colorado Prior Authorization List, Pg 147 Original policy |
| C7531 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal angioplasty with intravascular ultrasound (initial noncoro | Colorado Prior Authorization List, Pg 147 Original policy |
| C7534 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with atherectomy, includes angioplasty within the same vessel, when performe | Colorado Prior Authorization List, Pg 147 Original policy |
| C7535 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal stent placement(s), includes angioplasty within the same v | Colorado Prior Authorization List, Pg 147 Original policy |
| C7538 | Insertion of new or replacement of permanent pacemaker with ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricul | Colorado Prior Authorization List, Pg 147 Original policy |
| C7539 | Insertion of new or replacement of permanent pacemaker with atrial and ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for lef | Colorado Prior Authorization List, Pg 147 Original policy |
| C7540 | Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, dual lead system, with insertion of pacing electrode, cardiac venous system, for | Colorado Prior Authorization List, Pg 147 Original policy |
| C7552 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; wit | Colorado Prior Authorization List, Pg 147 Original policy |
| C7553 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; wit | Colorado Prior Authorization List, Pg 147 Original policy |
| C8002 | Preparation of skin cell suspension autograft, automated, including all enzymatic processing and device components (do not report with manual suspension preparation) | Colorado Prior Authorization List, Pg 147 Original policy |
| C8003 | Implantation of medial knee extraarticular implantable shock absorber spanning the knee joint from distal femur to proximal tibia, open, includes measurements, positioning and | Colorado Prior Authorization List, Pg 147 Original policy |
| C8903 | Magnetic resonance imaging with contrast, breast; unilateral | Colorado Prior Authorization List, Pg 147 Original policy |
| C8905 | Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral | Colorado Prior Authorization List, Pg 147 Original policy |
| C8906 | Magnetic resonance imaging with contrast, breast; bilateral | Colorado Prior Authorization List, Pg 147 Original policy |
| C8908 | Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral | Colorado Prior Authorization List, Pg 147 Original policy |
| C9047 | Injection, caplacizumab-yhdp, 1 mg | Colorado Prior Authorization List, Pg 147 Original policy |
| C9076 | Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Colorado Prior Authorization List, Pg 147 Original policy |
| C9077 | Injection, cabotegravir and rilpivirine, 2 mg/3 mg | Colorado Prior Authorization List, Pg 147 Original policy |
| C9079 | Injection, evinacumab-dgnb, 5 mg | Colorado Prior Authorization List, Pg 147 Original policy |
| C9081 | Idecabtagene vicleucel, up to 460 million autologous anti-BCMA CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Colorado Prior Authorization List, Pg 147 Original policy |
| C9085 | Injection, avalglucosidase alfa-ngpt, 4 mg | Colorado Prior Authorization List, Pg 147 Original policy |
| C9086 | Injection, anifrolumab-fnia, 1 mg | Colorado Prior Authorization List, Pg 147 Original policy |
| C9090 | Injection, plasminogen, human-tvmh, 1 mg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9094 | Injection, sutimlimab-jome, 10 mg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9096 | Injection, filgrastim-ayow, biosimilar, (Releuko), 1 mcg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9097 | Injection, faricimab-svoa, 0.1 mg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9098 | Ciltacabtagene autoleucel, up to 100 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures | Colorado Prior Authorization List, Pg 148 Original policy |
| C9149 | Injection, teplizumab-mzwv, 5 mcg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9151 | Injection, pegcetacoplan, 1 mg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9157 | Injection, tofersen, 1 mg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9160 | Injection, daxibotulinumtoxina-lanm, 1 unit | Colorado Prior Authorization List, Pg 148 Original policy |
| C9161 | Injection, aflibercept hd, 1 mg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9162 | Injection, avacincaptad pegol, 0.1 mg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9166 | Injection, secukinumab, IV, 1 mg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9167 | Injection, apadamtase alfa, 10 units | Colorado Prior Authorization List, Pg 148 Original policy |
| C9168 | Injection, mirikizumab-mrkz, 1 mg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9173 | Injection, filgrastim-txid (Nypozi), biosimilar, 1 mcg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9257 | Injection, bevacizumab, 0.25 mg | Colorado Prior Authorization List, Pg 148 Original policy |