Anthem Blue Cross Blue Shield of Colorado prior authorization, page 67
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 |
|---|---|---|
| E1831 | Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories | Colorado Prior Authorization List, Pg 152 Original policy |
| E1832 | Static progressive stretch finger device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories | Colorado Prior Authorization List, Pg 152 Original policy |
| E1841 | Static progressive stretch/patient actualized serial stretch shoulder device, with or without range of motion adjustment, includes all components and accessories | Colorado Prior Authorization List, Pg 152 Original policy |
| E1905 | Virtual reality cognitive behavioral therapy device (cbt), including pre- programmed therapy software | Colorado Prior Authorization List, Pg 152 Original policy |
| E2298 | Complex rehabilitative power wheelchair accessory, power seat elevation system, any type | Colorado Prior Authorization List, Pg 152 Original policy |
| E3200 | Gait modulation system, rhythmic auditory stimulation, including restricted therapy software, all components and accessories, prescription only | Colorado Prior Authorization List, Pg 152 Original policy |
| G0173 | Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session | Colorado Prior Authorization List, Pg 152 Original policy |
| G0251 | Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum five s | Colorado Prior Authorization List, Pg 152 Original policy |
| G0255 | Current Perception Threshold/Sensory Nerve Conduction Test, Per Limb | Colorado Prior Authorization List, Pg 152 Original policy |
| G0260 | Injection Procedure For Sacroiliac Joint; Provision Of Anesthetic, Ste | Colorado Prior Authorization List, Pg 152 Original policy |
| G0277 | Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval | Colorado Prior Authorization List, Pg 152 Original policy |
| G0281 | Electrical Stimulation, (Unattended), To One Or More Areas, For Chroni | Colorado Prior Authorization List, Pg 153 Original policy |
| G0282 | Electrical Stimulation, (Unatteded), To One Or More Areas, For Wound | Colorado Prior Authorization List, Pg 153 Original policy |
| G0283 | Electrical Stimulation (Unattended), To One Or More Areas For Indicati | Colorado Prior Authorization List, Pg 153 Original policy |
| G0289 | Arthroscopy, Knee, Surgical, For Removal Of Loose Body, Foreign Body | Colorado Prior Authorization List, Pg 153 Original policy |
| G0295 | Electromagnetic Stimulation, To One Or More Areas | Colorado Prior Authorization List, Pg 153 Original policy |
| G0329 | Electromagntic tx for ulcers | Colorado Prior Authorization List, Pg 153 Original policy |
| G0330 | Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia ca | Colorado Prior Authorization List, Pg 153 Original policy |
| G0339 | Robot lin-radsurg com, first | Colorado Prior Authorization List, Pg 153 Original policy |
| G0340 | Robt lin-radsurg fractx 2-5 | Colorado Prior Authorization List, Pg 153 Original policy |
| G0341 | Percutaneous islet celltrans | Colorado Prior Authorization List, Pg 153 Original policy |
| G0342 | Laparoscopy islet cell trans | Colorado Prior Authorization List, Pg 153 Original policy |
| G0343 | Laparotomy islet cell transp | Colorado Prior Authorization List, Pg 153 Original policy |
| G0398 | Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart r | Colorado Prior Authorization List, Pg 153 Original policy |
| G0399 | Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow | Colorado Prior Authorization List, Pg 153 Original policy |
| G0400 | Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels | Colorado Prior Authorization List, Pg 153 Original policy |
| G0428 | Collagen Meniscus Implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex) | Colorado Prior Authorization List, Pg 153 Original policy |
| G0429 | Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active | Colorado Prior Authorization List, Pg 153 Original policy |
| G0448 | Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac v | Colorado Prior Authorization List, Pg 153 Original policy |
| G0458 | Low dose rate (ldr) prostate brachytherapy services, composite rate | Colorado Prior Authorization List, Pg 153 Original policy |
| G0460 | Autologous platelet rich plasma or other blood-derived product for non-diabetic chronic wounds/ulcers, including as applicable phlebotomy, centrifugation or mixing, and all ot | Colorado Prior Authorization List, Pg 153 Original policy |
| G0465 | Autologous platelet rich plasma (PRP) or other blood-derived product for diabetic chronic wounds/ulcers, using an FDA-cleared device for this indication, (includes as applicab | Colorado Prior Authorization List, Pg 153 Original policy |
| G2082 | Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care profes | Colorado Prior Authorization List, Pg 153 Original policy |
| G2083 | Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care profes | Colorado Prior Authorization List, Pg 153 Original policy |
| G2168 | Services performed by a physical therapist assistant in the home health setting in the delivery of a safe and effective physical therapy maintenance program, each 15 minutes | Colorado Prior Authorization List, Pg 153 Original policy |
| G9143 | Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s) | Colorado Prior Authorization List, Pg 154 Original policy |
| G9147 | Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of | Colorado Prior Authorization List, Pg 154 Original policy |
| G9840 | RAS (KRAS and NRAS) gene mutation testing performed before initiation of anti- EGFR MoAb | Colorado Prior Authorization List, Pg 154 Original policy |
| G9841 | RAS (KRAS and NRAS) gene mutation testing not performed before initiation of anti-EGFR MoAb | Colorado Prior Authorization List, Pg 154 Original policy |
| H0004 | Behavioral health counseling and therapy, per 15 minutes | Colorado Prior Authorization List, Pg 154 Original policy |
| H0006 | Alcohol and/or drug services; case management | Colorado Prior Authorization List, Pg 154 Original policy |
| H0015 | Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment p | Colorado Prior Authorization List, Pg 154 Original policy |
| H0017 | Behavioral health; residential (hospital residential treatment program), without room and board, per diem | Colorado Prior Authorization List, Pg 154 Original policy |
| H0019 | Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, pe | Colorado Prior Authorization List, Pg 154 Original policy |
| H0023 | Behavioral health outreach service (planned approach to reach a targeted population) | Colorado Prior Authorization List, Pg 154 Original policy |
| H0035 | Mental health partial hospitalization, treatment, less than 24 hours | Colorado Prior Authorization List, Pg 154 Original policy |
| H0038 | Self-help/peer services, per 15 minutes | Colorado Prior Authorization List, Pg 154 Original policy |
| H0039 | Assertive community treatment, face-to-face, per 15 minutes | Colorado Prior Authorization List, Pg 154 Original policy |
| H0040 | Assertive community treatment program, per diem | Colorado Prior Authorization List, Pg 154 Original policy |
| H2021 | Community-based wrap-around services, per 15 minutes | Colorado Prior Authorization List, Pg 154 Original policy |