Anthem Blue Cross Blue Shield of Colorado prior authorization, page 79
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 |
|---|---|---|
| Q4150 | Allowrap ds or dry, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 167 Original policy |
| Q4151 | Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4152 | Dermapure, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4153 | Dermavest and plurivest, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4154 | Biovance, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4155 | Neoxflo or clarixflo, 1 mg | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4156 | Neox 100 or clarix 100, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4157 | Revitalon, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4158 | Kerecis omega3, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4159 | Affinity, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4160 | Nushield, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4161 | Bio-connekt wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4162 | WoundEx Flow, BioSkin Flow, 0.5 cc | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4163 | Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4164 | Helicoll, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4165 | Keramatrix or kerasorb, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4166 | Cytal, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4167 | Truskin, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4169 | Artacent wound, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4170 | Cygnus, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4171 | Interfyl, 1 mg | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4173 | Palingen or palingen xplus, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4174 | Palingen or promatrx, 0.36 mg per 0.25 cc | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4175 | Miroderm, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4176 | Neopatch or therion, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4177 | FlowerAmnioFlo, 0.1 cc | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4178 | Floweramniopatch, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4179 | Flowerderm, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4180 | Revita, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4181 | Amnio wound, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4183 | Surgigraft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4184 | Cellesta or cellesta duo, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4185 | Cellesta Flowable Amnion (25 mg per cc); per 0.5 cc | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4186 | Epifix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 168 Original policy |
| Q4187 | Epicord, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4188 | Amnioarmor, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4189 | Artacent AC, 1 mg | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4190 | Artacent ac, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4191 | Restorigin, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4192 | Restorigin, 1 cc | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4193 | Coll-e-derm, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4194 | Novachor, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4195 | Puraply, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4196 | Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4197 | Puraply xt, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4198 | Genesis amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4199 | Cygnus matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4200 | Skin te, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4201 | Matrion, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4202 | Keroxx (2.5g/cc), 1cc | Colorado Prior Authorization List, Pg 169 Original policy |