Anthem Blue Cross Blue Shield of Colorado prior authorization, page 66

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

Prior authorization codes
Code	Description	Source
E0665	Pneumatic Appliance Full Arm	Colorado Prior Authorization List, Pg 151 Original policy
E0666	Pneumatic Appliance Half Leg	Colorado Prior Authorization List, Pg 151 Original policy
E0667	Seg Pneumatic Appl Full Leg	Colorado Prior Authorization List, Pg 151 Original policy
E0668	Seg Pneumatic Appl Full Arm	Colorado Prior Authorization List, Pg 151 Original policy
E0669	Seg Pneumatic Appli Half Leg	Colorado Prior Authorization List, Pg 151 Original policy
E0670	Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk	Colorado Prior Authorization List, Pg 151 Original policy
E0671	Pressure Pneum Appl Full Leg	Colorado Prior Authorization List, Pg 151 Original policy
E0672	Pressure Pneum Appl Full Arm	Colorado Prior Authorization List, Pg 151 Original policy
E0673	Pressure Pneum Appl Half Leg	Colorado Prior Authorization List, Pg 151 Original policy
E0676	INTERMITTENT LIMB COMPRESSION DEVICE (INCLUDES ALL ACCESSORIES), NOT OTHERWISE	Colorado Prior Authorization List, Pg 151 Original policy
E0677	Non-pneumatic sequential compression garment, trunk	Colorado Prior Authorization List, Pg 151 Original policy
E0678	Non-pneumatic sequential compression garment, full leg	Colorado Prior Authorization List, Pg 151 Original policy
E0679	Non-pneumatic sequential compression garment, half leg	Colorado Prior Authorization List, Pg 151 Original policy
E0680	Non-pneumatic compression controller with sequential calibrated gradient pressure	Colorado Prior Authorization List, Pg 151 Original policy
E0681	Non-pneumatic compression controller without calibrated gradient pressure	Colorado Prior Authorization List, Pg 151 Original policy
E0682	Non-pneumatic sequential compression garment, full arm	Colorado Prior Authorization List, Pg 151 Original policy
E0683	Non-pneumatic, non-sequential, peristaltic wave compression pump	Colorado Prior Authorization List, Pg 151 Original policy
E0721	Transcutaneous electrical nerve stimulatory, stimulates nerves in the auricular region	Colorado Prior Authorization List, Pg 151 Original policy
E0732	Cranial electrotherapy stimulation (ces) system, any type	Colorado Prior Authorization List, Pg 151 Original policy
E0734	External upper limb tremor stimulator of the peripheral nerves of the wrist	Colorado Prior Authorization List, Pg 151 Original policy
E0735	Non-invasive vagus nerve stimulator	Colorado Prior Authorization List, Pg 151 Original policy
E0736	Transcutaneous tibial nerve stimulator	Colorado Prior Authorization List, Pg 151 Original policy
E0737	Transcutaneous tibial nerve stimulator, controlled by phone application	Colorado Prior Authorization List, Pg 151 Original policy
E0738	Upper extremity rehabilitation system providing active assistance to facilitate muscle re-education, includes microprocessor, all components and accessories	Colorado Prior Authorization List, Pg 151 Original policy
E0739	Rehabilitation system with interactive interface providing active assistance in rehabilitation therapy, includes all components and accessories, motors, microprocessors, senso	Colorado Prior Authorization List, Pg 151 Original policy
E0743	External lower extremity nerve stimulator for restless legs syndrome, each	Colorado Prior Authorization List, Pg 151 Original policy
E0745	Neuromuscular Stim For Shock	Colorado Prior Authorization List, Pg 151 Original policy
E0746	Electromyograph Biofeedback	Colorado Prior Authorization List, Pg 151 Original policy
E0748	Elec Osteogen Stim Spinal	Colorado Prior Authorization List, Pg 151 Original policy
E0752	Implantable neurostimulator electrode, each	Colorado Prior Authorization List, Pg 151 Original policy
E0754	Patient programmer (external) for use with implantable programmable neurostimulator pulse generator	Colorado Prior Authorization List, Pg 152 Original policy
E0756	Implantable Pulse Generator	Colorado Prior Authorization List, Pg 152 Original policy
E0760	Osteogen Ultrasound Stimltor	Colorado Prior Authorization List, Pg 152 Original policy
E0761	Non-Thermal Pulsed High Frequency Radiowaves, High Peak Power Electrom	Colorado Prior Authorization List, Pg 152 Original policy
E0762	Transcutaneous electrical joint stimulation device system, includes all accessories	Colorado Prior Authorization List, Pg 152 Original policy
E0764	Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer	Colorado Prior Authorization List, Pg 152 Original policy
E0765	FDA-approved nerve stimulator, for treatment of nausea and vomiting	Colorado Prior Authorization List, Pg 152 Original policy
E0769	Electric wound treatment dev	Colorado Prior Authorization List, Pg 152 Original policy
E0770	Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, n	Colorado Prior Authorization List, Pg 152 Original policy
E0782	Non-Programble Infusion Pump	Colorado Prior Authorization List, Pg 152 Original policy
E0783	Programmable Infusion Pump	Colorado Prior Authorization List, Pg 152 Original policy
E0786	Implantable Pump Replacement	Colorado Prior Authorization List, Pg 152 Original policy
E0986	Manual wheelchair accessory, power assist system	Colorado Prior Authorization List, Pg 152 Original policy
E1012	Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each	Colorado Prior Authorization List, Pg 152 Original policy
E1801	Static progressive stretch/patient actualized serial stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and ac	Colorado Prior Authorization List, Pg 152 Original policy
E1806	Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes	Colorado Prior Authorization List, Pg 152 Original policy
E1811	Static progressive stretch/patient actualized serial stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and acc	Colorado Prior Authorization List, Pg 152 Original policy
E1816	Static progressive stretch/patient actualized serial stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and ac	Colorado Prior Authorization List, Pg 152 Original policy
E1818	Static progressive stretch/patient actualized serial stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and acces	Colorado Prior Authorization List, Pg 152 Original policy
E1821	Replacement soft interface material/cuffs for bi-directional static progressive stretch device	Colorado Prior Authorization List, Pg 152 Original policy

Sources

Colorado Prior Authorization List