Anthem Blue Cross Blue Shield of Colorado prior authorization, page 80
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 |
|---|---|---|
| Q4203 | Derma-gide, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4204 | Xwrap, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4205 | Membrane graft or membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4206 | Fluid flow or fluid GF, 1 cc | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4208 | Novafix, per square cenitmeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4209 | Surgraft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4210 | Axolotl graft or axolotl dualgraft, per square centimeter | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4211 | Amnion bio or axobiomembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4212 | Allogen, per cc | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4213 | Ascent, 0.5 mg | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4214 | Cellesta cord, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4215 | Axolotl ambient or axolotl cryo, 0.1 mg | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4216 | Artacent cord, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4217 | Woundfix, biowound, woundfix plus, biowound plus, woundfix xplus or biowound xplus, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4218 | Surgicord, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4219 | Surgigraft-dual, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4220 | Bellacell hd or surederm, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 169 Original policy |
| Q4221 | Amniowrap2, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4222 | Progenamatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4224 | Human health factor 10 amniotic patch (hhf10-p), per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4225 | Amniobind or dermabind tl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4226 | MyOwn skin, includes harvesting and preparation procedures, per square centimeter | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4227 | Amniocore, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4229 | Cogenex amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4230 | Cogenex Flowable Amnion, per 0.5 cc | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4232 | Corplex, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4233 | SurFactor or NuDyn, per 0.5 cc | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4234 | Xcellerate, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4235 | Amniorepair or altiply, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4236 | Carepatch, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4237 | Cryo-cord, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4238 | Derm-maxx, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4239 | Amnio-maxx or amnio-maxx lite, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4240 | CoreCyte, for topical use only, per 0.5 cc | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4241 | PolyCyte, for topical use only, per 0.5 cc | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4242 | AmnioCyte Plus, per 0.5 cc | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4245 | AmnioText, per cc | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4246 | CoreText or ProText, per cc | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4247 | Amniotext patch, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4248 | Dermacyte amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4249 | Amniply, for topical use only, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4250 | Amnioamp-mp, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4251 | Vim, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4252 | Vendaje, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4253 | Zenith amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4254 | Novafix dl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4255 | Reguard, for topical use only, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4256 | Mlg-complete, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4257 | Relese, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |
| Q4258 | Enverse, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 170 Original policy |