Anthem Blue Cross Blue Shield of Colorado prior authorization, page 82
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 |
|---|---|---|
| Q4309 | Via matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4310 | Procenta, per 100 mg | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4311 | Acesso, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4312 | Acesso ac, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4313 | Dermabind fm, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4314 | Reeva ft, per square cenitmeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4315 | Regenelink amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4316 | Amchoplast, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4317 | Vitograft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4318 | E-graft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4319 | Sanograft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4320 | Pellograft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4321 | Renograft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4322 | Caregraft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4323 | Alloply, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4324 | Amniotx, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 172 Original policy |
| Q4325 | Acapatch, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4326 | Woundplus, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4327 | Duoamnion, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4328 | Most, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4329 | Singlay, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4330 | Total, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4331 | Axolotl graft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4332 | Axolotl dualgraft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4333 | Ardeograft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4334 | Amnioplast 1, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4335 | Amnioplast 2, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4336 | Artacent c, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4337 | Artacent trident, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4338 | Artacent velos, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4339 | Artacent vericlen, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4340 | Simpligraft, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4341 | Simplimax, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4342 | Theramend, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4343 | Dermacyte ac matrix amniotic membrane allograft, per square centimeter (add- on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4344 | Tri-membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4345 | Matrix hd allograft dermis, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4346 | Shelter dm matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4347 | Rampart dl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4348 | Sentry sl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4349 | Mantle dl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4350 | Palisade dm matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4351 | Enclose tl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4352 | Overlay sl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4353 | Xceed tl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4354 | Palingen dual-layer membrane and dual-layer palingen x-membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4355 | Abiomend xplus membrane and abiomend xplus hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4356 | Abiomend membrane and abiomend hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 173 Original policy |
| Q4357 | Xwrap plus, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 174 Original policy |
| Q4358 | Xwrap dual, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 174 Original policy |