Anthem Blue Cross Blue Shield of Colorado prior authorization, page 84

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

Prior authorization codes
Code	Description	Source
Q5141	Injection, adalimumab-aaty, biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5142	Injection, adalimumab-ryvk biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5143	Injection, adalimumab-adbm, biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5144	Injection, adalimumab-aacf (idacio), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5145	Injection, adalimumab-afzb (abrilada), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5146	Injection, trastuzumab-strf (hercessi), biosimilar, 10 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5147	Injection, aflibercept-ayyh (Pavblu), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5148	Injection, filgrastim-txid (Nypozi), biosimilar, 1 mcg	Colorado Prior Authorization List, Pg 175 Original policy
Q5149	Injection, aflibercept-abzv (Enzeevu), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5150	Injection, aflibercept-mrbb (Ahzantive), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5151	Injection, eculizumab-aagh (Epysqli), biosimilar, 2 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5152	Injection, eculizumab-aeeb (Bkemv), biosimilar, 2 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5153	Injection, aflibercept-yszy (opuviz), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5154	Injection, omalizumab-igec (Omlyclo), biosimilar, 5 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5155	Injection, aflibercept-jbvf (Yesafili), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5156	Injection, tocilizumab-anoh (Avtozma), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5157	Injection, denosumab-bmwo (Stoboclo/Osenvelt), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5158	Injection, denosumab-bnht (Bomyntra/Conexxence), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5159	Injection, denosumab-dssb (Ospomyv/Xbryk), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5160	Injection, bevacizumab-nwgd (jobevne), biosimilar, 10 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5161	Injection, denosumab-kyqq (aukelso/bosaya), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q5162	Injection, denosumab-nxxp (bildyos/bilprevda), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q9996	Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q9997	Injection, ustekinumab-ttwe (pyzchiva), intravenous, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q9998	Injection, ustekinumab-aekn (selarsdi), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
Q9999	Injection, ustekinumab-aauz (Otulfi), biosimilar, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
S0013	Esketamine, nasal spray, 1 mg	Colorado Prior Authorization List, Pg 175 Original policy
S0189	Testosterone pellet, 75 mg	Colorado Prior Authorization List, Pg 175 Original policy
S0196	Injectable poly-l-lactic acid, restorative implant, 1 ml, face (deep dermis, subcutaneous layers)	Colorado Prior Authorization List, Pg 175 Original policy
S0201	Partial Hospitalization Services, Less Than 24 Hours, Per Diem	Colorado Prior Authorization List, Pg 175 Original policy
S0353	Treatment planning and care coordination management for cancer initial treatment	Colorado Prior Authorization List, Pg 175 Original policy
S0354	Treatment planning and care coordination management for cancer established patient with a change of regimen	Colorado Prior Authorization List, Pg 175 Original policy
S1091	Stent, non-coronary, temporary, with delivery system (propel)	Colorado Prior Authorization List, Pg 175 Original policy
S2053	Transplantation Of Small Int	Colorado Prior Authorization List, Pg 175 Original policy
S2054	Transplantation Of Multivisc	Colorado Prior Authorization List, Pg 176 Original policy
S2055	Harvesting Of Donor Multivis	Colorado Prior Authorization List, Pg 176 Original policy
S2060	Lobar Lung Transplantation	Colorado Prior Authorization List, Pg 176 Original policy
S2061	Donor Lobectomy (Lung)	Colorado Prior Authorization List, Pg 176 Original policy
S2065	Simultaneous pancreas kidney transplantation	Colorado Prior Authorization List, Pg 176 Original policy
S2066	Breast reconstruction with gluteal artery perforator (GAP) flap, including	Colorado Prior Authorization List, Pg 176 Original policy
S2067	Breast reconstruction of a single breast with "stacked" deep inferior	Colorado Prior Authorization List, Pg 176 Original policy
S2068	Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SI	Colorado Prior Authorization List, Pg 176 Original policy
S2080	Laser-assisted uvulopalatoplasty (LAUP)	Colorado Prior Authorization List, Pg 176 Original policy
S2102	Islet Cell Tissue Transplant	Colorado Prior Authorization List, Pg 176 Original policy
S2103	Adrenal Tissue Transplant	Colorado Prior Authorization List, Pg 176 Original policy
S2112	Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)	Colorado Prior Authorization List, Pg 176 Original policy
S2117	Arthroereisis, subtalar	Colorado Prior Authorization List, Pg 176 Original policy
S2118	Metal-on-metal total hip resurfacing including acetabular and femoral components	Colorado Prior Authorization List, Pg 176 Original policy
S2120	Low Density Lipoprotein(Ldl)	Colorado Prior Authorization List, Pg 176 Original policy
S2140	Cord Blood Harvesting	Colorado Prior Authorization List, Pg 176 Original policy

Sources

Colorado Prior Authorization List