Blue Shield of California Promise Health Plan prior authorization
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 |
|---|---|---|
| 00170 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 15011 | Harvest of skin for skin cell suspension autograft; first 25 sq cm or less | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 17999 | UNLISTED PX SKIN MUC MEMBRANE &SUBQ TISSUE | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 19300 | MASTECTOMY GYNECOMASTIA | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 19316 | MASTOPEXY | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 19318 | BREAST REDUCTION | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 19325 | BREAST AUGMENTATION WITH IMPLANT | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21120 | GENIOPLASTY AUGMENTATION | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21121 | GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21122 | GENIOPLASTY 2/> SLIDING OSTEOTOMIES | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21123 | GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21127 | AGMNTJ MNDBLR BDY/ANGL W/B1 GRF ONLAY/INTERPOSAL | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21137 | REDUCTION FOREHEAD CONTOURING ONLY | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21138 | RDCTJ FHD CNTRG&PROSTHETIC MATRL/BONE GRAFT | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21193 | RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21194 | RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRF | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21195 | RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21196 | RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FIXJ | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21208 | OSTEOPLASTY FACIAL BONES AUGMENTATION | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21209 | OSTEOPLASTY FACIAL BONES REDUCTION | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21210 | GRAFT BONE NASAL/MAXILLARY/MALAR AREAS | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21270 | MALAR AUGMENTATION PROSTHETIC MATERIAL | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 21299 | UNLISTED CRANIOFACIAL&MAXILLOFACIAL PROCEDURE | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 22612 | Single-Level Lumbar Spinal Fusion, Posterior or Posterolateral Approach | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 22860 | SPINAL INSTRUMENTATION PROCEDURES | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 30400 | RHINP PRIM LAT&ALAR CRTLGS&/ELVTN NSL TIP | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 30410 | RHINP PRIM COMPLETE XTRNL PARTS | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 30420 | RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 30430 | RHINOPLASTY SECONDARY MINOR REVISION | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 30435 | RHINOPLASTY SECONDARY INTERMEDIATE REVISION | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 30450 | RHINOPLASTY SECONDARY MAJOR REVISION | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 30468 | IMPLANT(S) | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 31242 | Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation, posterior nasal nerve. | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 31243 | Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve. | Medi-Cal Prior Authorization List, Pg 2 Original policy |
| 31599 | UNLISTED PROCEDURE LARYNX | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 32851 | LUNG TRANSPLANT SINGLE | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 32852 | LUNG TRANSPLANT WITH BYPASS | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 32853 | LUNG TRANSPLANT DOUBLE | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 32854 | LUNG TRANSPLANT WITH BYPASS | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 33276 | Insertion of phrenic nerve stimulator system (pulse generator and stimulating lead[s]), including vessel catheterization, all imaging guidance, and pulse generator initial analysis with diagnostic mode activation, when performed. | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 33277 | Insertion of phrenic nerve stimulator transvenous sensing lead (List separately in addition to code for primary procedure). | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 33278 | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; system, including pulse generator and lead(s). | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 33279 | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) only. | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 33280 | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator only. | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 33935 | TRANSPLANTATION HEART/LUNG | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 33945 | TRANSPLANTATION OF HEART | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 34510 | TRANSPOSITION OF VEIN VALVE | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 38204 | BL DONOR SEARCH MANAGEMENT | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 38205 | HARVEST ALLOGENEIC STEM CELL | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 38206 | HARVEST AUTO STEM CELLS | Medi-Cal Prior Authorization List, Pg 3 Original policy |