Anthem Blue Cross Blue Shield of Colorado prior authorization, page 64
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 |
|---|---|---|
| C9304 | Injection, marstacimab-hncq, 0.5 mg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9305 | Injection, nipocalimab-aahu, 3 mg | Colorado Prior Authorization List, Pg 148 Original policy |
| C9352 | Microporous collagen implantable tube (NeuraGen Nerve Guide), per cm length | Colorado Prior Authorization List, Pg 148 Original policy |
| C9353 | Microporous collagen implantable slit tube (NeuraWrap Nerve Protector), per cm length | Colorado Prior Authorization List, Pg 148 Original policy |
| C9354 | Acellular pericardial tissue matrix of nonhuman origin (Veritas), per sq cm | Colorado Prior Authorization List, Pg 148 Original policy |
| C9355 | Collagen nerve cuff (NeuroMatrix), per 0.5 cm length | Colorado Prior Authorization List, Pg 148 Original policy |
| C9356 | Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector Sheet), per sq cm | Colorado Prior Authorization List, Pg 148 Original policy |
| C9358 | Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm | Colorado Prior Authorization List, Pg 148 Original policy |
| C9359 | Porous purified collagen matrix bone void filler (Integra Mozaik Osteoconductive Scaffold Putty, Integra OS Osteoconductive Scaffold Putty), per 0.5 cc | Colorado Prior Authorization List, Pg 148 Original policy |
| C9360 | Dermal substitute, native, nondenatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm | Colorado Prior Authorization List, Pg 148 Original policy |
| C9361 | Collagen matrix nerve wrap (NeuroMend Collagen Nerve Wrap), per 0.5 cm length | Colorado Prior Authorization List, Pg 148 Original policy |
| C9362 | Porous purified collagen matrix bone void filler (Integra Mozaik Osteoconductive Scaffold Strip), per 0.5 cc | Colorado Prior Authorization List, Pg 148 Original policy |
| C9363 | Skin substitute (Integra Meshed Bilayer Wound Matrix), per square cm | Colorado Prior Authorization List, Pg 148 Original policy |
| C9364 | Porcine implant, Permacol, per sq cm | Colorado Prior Authorization List, Pg 148 Original policy |
| C9600 | Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch | Colorado Prior Authorization List, Pg 148 Original policy |
| C9601 | Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (list | Colorado Prior Authorization List, Pg 148 Original policy |
| C9602 | Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch | Colorado Prior Authorization List, Pg 148 Original policy |
| C9603 | Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary art | Colorado Prior Authorization List, Pg 148 Original policy |
| C9604 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary | Colorado Prior Authorization List, Pg 148 Original policy |
| C9605 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary | Colorado Prior Authorization List, Pg 148 Original policy |
| C9607 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluti | Colorado Prior Authorization List, Pg 149 Original policy |
| C9608 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluti | Colorado Prior Authorization List, Pg 149 Original policy |
| C9727 | Insertion of implants into the soft palate; minimum of 3 implants | Colorado Prior Authorization List, Pg 149 Original policy |
| C9734 | Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (mr) guidance | Colorado Prior Authorization List, Pg 149 Original policy |
| C9751 | Bronchoscopy, rigid or flexible, transbronchial ablation of lesion(s) by microwave energy, including fluoroscopic guidance, when performed, with computed tomography acquisiti | Colorado Prior Authorization List, Pg 149 Original policy |
| C9752 | Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum | Colorado Prior Authorization List, Pg 149 Original policy |
| C9762 | Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging | Colorado Prior Authorization List, Pg 149 Original policy |
| C9763 | Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging | Colorado Prior Authorization List, Pg 149 Original policy |
| C9764 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, includes angioplasty within the sam | Colorado Prior Authorization List, Pg 149 Original policy |
| C9765 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, and transluminal stent placement(s) | Colorado Prior Authorization List, Pg 149 Original policy |
| C9766 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and atherectomy, includes angioplast | Colorado Prior Authorization List, Pg 149 Original policy |
| C9767 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and transluminal stent placement(s) | Colorado Prior Authorization List, Pg 149 Original policy |
| C9772 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy, includes angioplasty within the same vessel (s), when perfo | Colorado Prior Authorization List, Pg 149 Original policy |
| C9773 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty | Colorado Prior Authorization List, Pg 149 Original policy |
| C9774 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel | Colorado Prior Authorization List, Pg 149 Original policy |
| C9775 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includ | Colorado Prior Authorization List, Pg 149 Original policy |
| C9781 | Arthroscopy, shoulder, surgical; with implantation of subacromial spacer (e.g., balloon), includes debridement (e.g., limited or extensive), subacromial decompression, acromio | Colorado Prior Authorization List, Pg 149 Original policy |
| C9785 | Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components | Colorado Prior Authorization List, Pg 149 Original policy |
| C9796 | Repair of enterocutaneous fistula small intestine or colon (excluding anorectal fistula) with plug (e.g., porcine small intestine submucosa [SIS]) | Colorado Prior Authorization List, Pg 149 Original policy |
| C9807 | Nerve stimulator, percutaneous, peripheral (e.g., sprint peripheral nerve stimulation system), including electrode and all disposable system components, non-opioid medical dev | Colorado Prior Authorization List, Pg 149 Original policy |
| C9808 | Nerve cryoablation probe (e.g., cryoice, cryosphere, cryosphere max, cryoice cryosphere, cryoice cryo2), including probe and all disposable system components, non-opioid medic | Colorado Prior Authorization List, Pg 149 Original policy |
| C9809 | Cryoneurolysis needle (e.g., iovera system), including needle/tip and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid med | Colorado Prior Authorization List, Pg 149 Original policy |
| D7810 | open reduction of dislocation | Colorado Prior Authorization List, Pg 149 Original policy |
| D7820 | closed reduction of dislocation | Colorado Prior Authorization List, Pg 149 Original policy |
| D7830 | manipulation under anesthesia | Colorado Prior Authorization List, Pg 149 Original policy |
| D7840 | condylectomy | Colorado Prior Authorization List, Pg 149 Original policy |
| D7850 | surgical discectomy, with/without implant | Colorado Prior Authorization List, Pg 149 Original policy |
| D7852 | disc repair | Colorado Prior Authorization List, Pg 150 Original policy |
| D7854 | synovectomy | Colorado Prior Authorization List, Pg 150 Original policy |
| D7856 | myotomy | Colorado Prior Authorization List, Pg 150 Original policy |