Anthem Blue Cross Blue Shield of Colorado prior authorization, page 78
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 |
|---|---|---|
| Q2058 | Obecabtagene autoleucel, 10 up to 400 million cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per infusion | Colorado Prior Authorization List, Pg 166 Original policy |
| Q3001 | Brachytherapy Radioelements | Colorado Prior Authorization List, Pg 166 Original policy |
| Q3027 | Injection, interferon beta-1a, 1 mcg for intramuscular use | Colorado Prior Authorization List, Pg 166 Original policy |
| Q3028 | Injection, interferon beta-1a, 1 mcg for subcutaneous use | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4074 | Iloprost, Inhalation Solution, Fda-Approved Final Product, Non-Compounded, Administered Through Dme, Unit Dose Form, Up | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4081 | INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS) | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4100 | Skin substitute, not otherwise specified | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4101 | Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4102 | Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4103 | Oasis burn matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4104 | Integra bilayer matrix wound dressing (bmwd), per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4105 | Integra dermal regeneration template (drt) or integra omnigraft dermal regeneration matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4106 | Dermagraft, per square centimeter | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4107 | Graftjacket, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4108 | Integra matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4110 | Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4111 | Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4112 | Cymetra, injectable, 1cc | Colorado Prior Authorization List, Pg 166 Original policy |
| Q4113 | GRAFTJACKET XPRESS, injectable, 1cc | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4114 | Integra flowable wound matrix, injectable, 1 cc | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4115 | Alloskin, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4116 | Alloderm, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4117 | Hyalomatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4118 | Matristem micromatrix, 1 mg | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4121 | Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4122 | Dermacell, dermacell awm or dermacell awm porous, per square centimeter (add- on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4123 | Alloskin rt, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4124 | Oasis ultra tri-layer wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4125 | Arthroflex, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4126 | Memoderm, dermaspan, tranzgraft or integuply, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4127 | Talymed, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4128 | Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4130 | Strattice tm, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4132 | Grafix core and grafixpl core, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4133 | Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4134 | Hmatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4135 | Mediskin, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4136 | Ez-derm, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4137 | Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4138 | Biodfence dryflex, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4139 | Amniomatrix or biodmatrix, injectable, 1 cc | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4140 | Biodfence, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4141 | Alloskin ac, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4142 | Xcm biologic tissue matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4143 | Repriza, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4145 | Epifix, injectable, 1 mg | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4146 | Tensix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4147 | Architect, architect px, or architect fx, extracellular matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4148 | Neox cord 1k, neox cord rt, or clarix cord 1k, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4149 | Excellagen, 0.1 cc | Colorado Prior Authorization List, Pg 167 Original policy |