Anthem Blue Cross Blue Shield of Colorado prior authorization, page 83
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 |
|---|---|---|
| Q4359 | Choriply, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 174 Original policy |
| Q4360 | Amchoplast fd, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 174 Original policy |
| Q4361 | Epixpress, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 174 Original policy |
| Q4362 | Cygnus disk, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 174 Original policy |
| Q4363 | Amnio burgeon membrane and hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 174 Original policy |
| Q4364 | Amnio burgeon xplus membrane and xplus hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 174 Original policy |
| Q4365 | Amnio burgeon dual-layer membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 174 Original policy |
| Q4366 | Dual layer amnio burgeon x-membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 174 Original policy |
| Q4367 | Amniocore sl, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 174 Original policy |
| Q4369 | Amnioplast 3, per square centimeter (add-on, list separately in addition to primary procedure) | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5098 | Injection, ustekinumab-srlf (imuldosa), biosimilar, 1 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5099 | Injection, ustekinumab-stba (steqeyma), biosimilar, 1 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5100 | Injection, ustekinumab-kfce (yesintek), biosimilar, 1 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5101 | Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5103 | Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5104 | Injection, infliximab-abda, biosimilar, (renflexis), 10 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5105 | Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for ESRD on dialysis), 100 units | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5106 | Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for non-ESRD use), 1000 units | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5107 | Injection, bevacizumab-awwb, biosimilar, (Mvasi), 10 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5108 | Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5109 | Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5110 | Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5111 | Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5112 | Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5113 | Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5114 | Injection, trastuzumab-dkst, biosimilar, (Ogivri), 10 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5115 | Injection, rituximab-abbs, biosimilar, 10 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5116 | Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5118 | Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5119 | Injection, rituximab-pvvr, biosimilar, (RUXIENCE), 10 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5120 | Injection, pegfilgrastim-bmez (ziextenzo), biosimilar, 0.5 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5121 | Injection, infliximab-axxq, biosimilar, (AVSOLA), 10 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5122 | Injection, pegfilgrastim-apgf (nyvepria), biosimilar, 0.5 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5123 | Injection, rituximab-arrx, biosimilar, (riabni), 10 m | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5124 | Injection, ranibizumab-nuna, biosimilar, (Byooviz), 0.1 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5125 | Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5126 | Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg | Colorado Prior Authorization List, Pg 174 Original policy |
| Q5127 | Injection, pegfilgrastim-fpgk (stimufend), biosimilar, 0.5 mg | Colorado Prior Authorization List, Pg 175 Original policy |
| Q5128 | Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg | Colorado Prior Authorization List, Pg 175 Original policy |
| Q5129 | Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg | Colorado Prior Authorization List, Pg 175 Original policy |
| Q5130 | Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg | Colorado Prior Authorization List, Pg 175 Original policy |
| Q5131 | Injection, adalimumab-aacf (idacio), biosimilar, 20 mg | Colorado Prior Authorization List, Pg 175 Original policy |
| Q5132 | Injection, adalimumab-afzb (abrilada), biosimilar, 10 mg | Colorado Prior Authorization List, Pg 175 Original policy |
| Q5133 | Injection, tocilizumab-bavi (Tofidence), biosimilar, 1 mg | Colorado Prior Authorization List, Pg 175 Original policy |
| Q5134 | Injection, natalizumab-sztn (Tyruko), biosimilar, 1 mg | Colorado Prior Authorization List, Pg 175 Original policy |
| Q5135 | Injection, tocilizumab-aazg (tyenne), biosimilar, 1 mg | Colorado Prior Authorization List, Pg 175 Original policy |
| Q5136 | Injection, denosumab-bbdz (jubbonti/wyost), biosimilar, 1 mg | Colorado Prior Authorization List, Pg 175 Original policy |
| Q5137 | Injection, ustekinumab-auub (Wezlana), biosimilar, SC, 1 mg | Colorado Prior Authorization List, Pg 175 Original policy |
| Q5138 | Injection, ustekinumab-auub (Wezlana), biosimilar, IV, 1 mg | Colorado Prior Authorization List, Pg 175 Original policy |
| Q5140 | Injection, adalimumab-fkjp, biosimilar, 1 mg | Colorado Prior Authorization List, Pg 175 Original policy |