Blue Shield of California Promise Health Plan prior authorization, page 12
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 |
|---|---|---|
| E2386 | PWR WC FOAM FILLED DRIVE WHEEL TIRE REPL ONLY EA | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| E2387 | PWR WC FOAM FILLED CASTER TIRE REPL ONLY EACH | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| E2388 | PWR WC FOAM DRIVE WHEEL TIRE REPL ONLY EACH | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| E2389 | PWR WC FOAM CASTER TIRE REPLACEMENT ONLY EACH | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| E2390 | PWR WC SOLID DRIVE WHEEL TIRE REPL ONLY EACH | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| E2391 | PWR WC SOLID CASTER TIRE REPLACEMENT ONLY EACH | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| E2392 | PWR WC SOLID CASTER TIRE INTEGRTED WHEEL REPL EA | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| E2394 | PWR WC DRIVE WHEEL EXCLUDES TIRE REPL ONLY EACH | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| E2396 | PWR WC CASTER FORK REPLACEMENT ONLY EACH | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| E2397 | POWER WHLCHAIR ACCESSORY LITHIUM-BASED BATTRY EA | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| E2398 | WC DYNAMIC POS BACK HARDWARE | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| E2402 | NEG PRESS WOUND THERAPY ELEC PUMP STATION/PRTBLE | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| E2510 | SPCH GEN DEVC SYNTHESIZD MX METH MESS&DEVC ACCSS | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| E2512 | ACCESS SPEECH GENERATING DEVICE MOUNTING SYSTEM | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| G0330 | Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating room | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| G0552 | Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| G0553 | First 20 minutes of monthly treatment management services directly related to the patient's therapeutic use of the digital mental health treatment (DMHT) device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing information related to the use of the DMHT device, including patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month | Medi-Cal Prior Authorization List, Pg 25 Original policy |
| G0554 | Each additional 20 minutes of monthly treatment management services directly related to the patient's therapeutic use of the digital mental health treatment (DMHT) device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing data generated from the DMHT device from patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| G0562 | Therapeutic radiology simulation-aided field setting; complex, including acquisition of PET and CT imaging data required for radiopharmaceutical-directed radiation therapy treatment planning (i.e., modeling) | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| G0563 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance and real-time positron emissions-based delivery adjustments to 1 or more lesions, entire course not to exceed 5 fractions | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| G0681 | Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) nonsheet form skin substitute for a wound surface area up to 100 sq cm; first 25 sq cm or less of wound surface area | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| G0682 | Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) nonsheet form skin substitute for a wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure) | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| G0683 | Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) nonsheet form skin substitute graft for a wound surface greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| G0684 | Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) nonsheet form skin substitute graft for a wound surface greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure) | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| H0031 | MENTAL HEALTH ASSESSMENT, BY NON-PHYSICIAN | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| H0032 | MENTAL HEALTH SERVICE PLAN DEVELOPMENT BY NON-PHYSICIAN | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| H0046 | MENTAL HEALTH SERVICES NOT OTHERWISE SPECIFIED | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| H2014 | SKILLS TRAINING AND DEVELOPMENT | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| H2019 | THERAPEUTIC BEHAVIORAL SERVICES PER 15 MINUTES | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| K0002 | STANDARD HEMI WHEELCHAIR | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| K0003 | LIGHTWEIGHT WHEELCHAIR | Medi-Cal Prior Authorization List, Pg 26 Original policy |
| K0004 | HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0005 | ULTRALIGHTWEIGHT WHEELCHAIR | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0010 | STANDARD-WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0011 | STD-WT FRME MOTRIZD/PWR WHLCHAIR W/PROG CNTRL | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0012 | LIGHTWEIGHT PORTABLE MOTORIZED/POWER WHEELCHAIR | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0013 | Custom Power Whlchr Base | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0014 | OTHER MOTORIZED/POWER WHEELCHAIR BASE | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0015 | DETACHABLE NONADJUSTABLE HEIGHT ARMREST EACH | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0017 | DETACH ADJUST ARMREST BASE | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0018 | DETACH ADJUST ARMRST UPPER | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0019 | ARM PAD REPL, EACH | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0038 | LEG STRAP EACH | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0039 | LEG STRAP H STYLE EACH | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0040 | ADJUSTABLE ANGLE FOOTPLATE EACH | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0042 | STANDARD SIZE FTPLATE REP EA | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0043 | FTRST LOWR EXTEN TUBE REP EA | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0044 | FTRST UPR HANGER BRAC REP EA | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0045 | FTRST COMPL ASSEMBLY REPL EA | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0046 | ELEV LGRST LWR EXTEN REPL EA | Medi-Cal Prior Authorization List, Pg 27 Original policy |