Anthem Blue Cross Blue Shield of Colorado prior authorization, page 81
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 |
|---|---|---|
| Q4259 | Celera dual layer or celera dual membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4260 | Signature apatch, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4261 | Tag, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4262 | Dual layer impax membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4263 | Surgraft tl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4264 | Cocoon membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4265 | Neostim tl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4266 | Neostim membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4267 | Neostim dl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4268 | Surgraft ft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4269 | Surgraft xt, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4270 | Complete sl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4271 | Complete ft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4272 | Esano a, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4273 | Esano aaa, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4274 | Esano ac, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4275 | Esano aca, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4276 | Orion, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4277 | Woundplus membrane or e-graft, per square centimeter | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4278 | Epieffect, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4279 | Vendaje ac, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4280 | Xcell amnio matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4281 | Barrera sl or barrera dl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4282 | Cygnus dual, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4283 | Biovance tri-layer or biovance 3l, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4284 | Dermabind sl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4285 | Nudyn dl or nudyn dl mesh, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4286 | Nudyn sl or nudyn slw, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4287 | Dermabind dl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4288 | Dermabind ch, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4289 | Revoshield + amniotic barrier, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4290 | Membrane wrap-hydro, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4291 | Lamellas xt, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 171 Original policy |
| Q4292 | Lamellas, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4293 | Acesso dl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4294 | Amnio quad-core, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4295 | Amnio tri-core amniotic, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4296 | Rebound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4297 | Emerge matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4298 | Amniocore pro, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4299 | Amniocore pro+, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4300 | Acesso tl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4301 | Activate matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4302 | Complete aca, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4303 | Complete aa, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4304 | Grafix plus, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4305 | American amnion ac tri-layer, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4306 | American amnion ac, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4307 | American amnion, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4308 | Sanopellis, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |