Blue Shield of California Promise Health Plan prior authorization, page 10
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 |
|---|---|---|
| E0967 | MAN WC RIM/PROJECTION REP EA | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E0971 | MNL WHEELCHAIR ACCESSORY ANTI-TIPPING DEVC EACH | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E0973 | WC ACCSS ADJUSTBL HT DTACH ARMRST CMPL ASSMBL EA | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E0974 | MANUAL WHEELCHAIR ACCESS ANTI-ROLLBACK DEVICE EA | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E0978 | WHLCHAIR ACSS PSTN BELT/SFTY BELT/PELV STRAP EA | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E0981 | WHEELCHAIR ACCESS SEAT UPHLSTR REPLCMT ONLY EA | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E0982 | WHEELCHAIR ACCESS BACK UPHLSTR REPLCMT ONLY EA | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E0983 | MNL WC ACSS PWR ADD-ON CONVRT MNL WC MOTRIZD WC | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E0984 | MNL WC ACSS PWR ADD-ON CONVRT MNL WC MOTRIZD WC | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E0985 | WHEELCHAIR ACCESSORY SEAT LIFT MECHANISM | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E0986 | MAN W/C PUSH-RIM POWR SYSTEM | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E0990 | WHEELCHAIR ACCESS ELEV LEG REST CMPL ASSMBL EA | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E0995 | WC CALF REST, PAD REPLACEMNT | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1002 | WHEELCHAIR ACCESS POWER SEATING SYSTEM TILT ONLY | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1003 | WC ACSS PWR SEAT SYS RECLINE W/O SHEAR RDUC | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1004 | WC ACSS PWR SEAT SYS RECLINE W/MECH SHEAR RDUC | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1005 | WC ACSS PWR SEAT SYS RECLINE W/PWR SHEAR RDUC | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1006 | WC ACSS PWR SEAT SYS TILT&RECLINE NO SHEAR RDUC | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1007 | WC ACSS PWR SEAT TILT&RECLINE MECH SHEAR RDUC | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1008 | WC ACSS PWR SEAT TILT&RECLINE W/PWR SHEAR RDUC | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1009 | WC ACCSS ADD PWR SEAT MECH LINKD LEG ELEV SYS EA | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1010 | WC ACCSS ADD PWR SEAT SYS PWR LEG ELEV SYS EACH | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1012 | CTR MOUNT PWR ELEV LEG REST | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1014 | RECLIN BACK ADDITION PEDIATRIC SIZE WHEELCHAIR | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1016 | SHOCK ABSORBER FOR POWER WHEELCHAIR EACH | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1018 | HEVY DUTY SHOCK ABSORBR HEVY/XTRA HEVY PWR WC EA | Medi-Cal Prior Authorization List, Pg 22 Original policy |
| E1020 | Residual limb support system | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1022 | Wheelchair transportation securement system, of any type, includes all components and accessories. | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1023 | Wheelchair transit securement system, includes all components and accessories | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1028 | WC ACCSS MANL SWINGAWAY OTH CNTRL INTRFCE/PSTN | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1029 | WHEELCHAIR ACCESSORY VENTILATOR TRAY FIXED | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1031 | ROLLABOUT CHAIR ANY&ALL TYPES W/CASTERS 5 IN/GT | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1032 | Wheelchair accessory, manual swingaway, retractable or removable mounting hardware used with joystick or other drive control interface | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1033 | Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for headrest, cushioned, any type | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1034 | Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for lateral trunk or hip support, any type | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1035 | MULTI-PSTN PT TRNSF SYS W/SEAT PT WT </= 300 LBS | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1036 | MULTI-PSTN PT TRNSF SYS EXTRA WIDE PT >300 LBS | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1037 | TRANSPORT CHAIR PEDIATRIC SIZE | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1038 | TRNSPRT CHAIR ADLT SZ PT WT CAP TO&INCL 300 LBS | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1226 | WHLCHAIR ACCESS MANUAL FULL RECLINING BACK EACH | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1228 | SPECIAL BACK HEIGHT FOR WHEELCHAIR | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1230 | PWR OPERATED VEH SPEC BRAND NAME & MODEL NUMBER | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1232 | WC PED SZ TILT-IN-SPACE FOLD ADJUSTBL W/SEAT SYS | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1234 | WC PED SZ TILT-IN-SPACE FOLD ADJUSTBL W/O SEAT | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1236 | WHLCHAIR PED SIZE FOLD ADJUSTBL W/SEATING SYSTEM | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1239 | POWER WHEELCHAIR PEDIATRIC SIZE NOS | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1353 | REGULATOR | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1355 | STAND/RACK | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1392 | PORTABLE OXYGEN CONCENTRATOR RENTAL | Medi-Cal Prior Authorization List, Pg 23 Original policy |
| E1399 | DURABLE MEDICAL EQUIPMENT MISCELLANEOUS | Medi-Cal Prior Authorization List, Pg 23 Original policy |