Blue Shield of California Promise Health Plan prior authorization, page 13
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 |
|---|---|---|
| K0052 | SWINGAWAY DETACH FTREST REPL | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0053 | ELEVATING FOOTRESTS ARTICULATING EACH | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0069 | RR WHL COMPL SOL TIRE REP EA | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0070 | REAR WHL ASSMBL CMPL-PNEUMAT TIRE SPOKE/MOLD EA | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0071 | FR CSTR COMP PNE TIRE REP EA | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0072 | FR CSTR SEMI-PNE TIRE REP EA | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0077 | FR CSTR ASMB SOL TIRE REP EA | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0108 | OTHER ACCESSORIES | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0195 | ELEVATING LEGREST PAIR | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0606 | AUTO EXT DEFIB W/INTGR ECG ANALY GARMENT TYPE | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0743 | PORTABLE HOME SUCTION PUMP | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0744 | ABSORP DRG <= 16 SUC PUMP | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0745 | ABSORP DRG >16 <=48 SUC PUMP | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0746 | ABSORP DRG >48 SUC PUMP | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0800 | PWR OP VEH GRP 1 STD PT WT CAP TO & INCL 300 LBS | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0801 | PWR OP VEH GRP 1 HEAVY DUTY PT 301 TO 450 LBS | Medi-Cal Prior Authorization List, Pg 27 Original policy |
| K0802 | PWR OP VEH GRP 1 VERY HEAVY DUTY PT 451-600 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0806 | PWR OP VEH GRP 2 STD PT WT CAP TO & INCL 300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0807 | PWR OP VEH GRP 2 HEAVY DUTY PT 301 TO 450 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0808 | PWR OP VEH GRP 2 VERY HEAVY DUTY PT 451-600 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0812 | POWER OPERATED VEHICLE NOT OTHERWISE CLASSIFIED | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0813 | PWR WC GRP 1 STD PORT SLING SEAT PT TO 300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0814 | PWR WC GRP 1 STD PORT CAPT CHAIR PT TO 300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0815 | PWR WC GRP 1 STD SLING SEAT PT UP TO &= 300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0816 | PWR WC GRP 1 STD CAPTAINS CHAIR PT TO &=300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0820 | PWR WC GRP 2 STD PORT SLING SEAT PT TO &=300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0821 | PWR WC GRP 2 STD PORT CAPT CHAIR PT TO &=300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0822 | PWR WC GRP 2 STD SLING SEAT PT TO &=300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0823 | PWR WC GRP 2 STD CAPTAINS CHAIR PT TO &=300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0824 | PWR WC GRP 2 HEVY DUTY SLING SEAT PT 301-450 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0825 | PWR WC GRP 2 HEVY DUTY CAPT CHAIR PT 301-450 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0826 | PWR WC GRP 2 VRY HVY DTY SLNG SEAT PT 451-600 LB | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0827 | PWR WC GRP 2 VRY HVY DTY CAPT CHR PT 451-600 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0828 | PWR WC GRP 2 XTRA HVY DUTY SLING SEAT PT 601LB/> | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0829 | PWR WC GRP 2 XTRA HVY DUTY CHAIR PT 601 LBS/> | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0830 | PWR WC GRP 2 STD SEAT ELEV SLING PT TO &=300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0831 | PWR WC GRP 2 STD SEAT ELEV CAP CHR PT TO 300 LB | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0835 | PWR WC GRP 2 STD 1 PWR SLING SEAT PT TO 300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0836 | PWR WC GRP 2 STD 1 PWR CAPT CHAIR PT TO 300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0837 | PWR WC GRP 2 HVY 1 PWR SLING SEAT PT 301-450 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0838 | PWR WC GRP 2 HVY 1 PWR CAPT CHAIR PT 301-450 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0839 | PWR WC GRP 2 VRY HVY 1 PWR SLING PT 451-600 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0840 | PWR WC GRP 2 XTRA HVY 1 PWR SLING PT 601 LBS/> | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0841 | PWR WC GRP 2 MX PWR SLING SEAT PT TO &=300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0842 | PWR WC GRP 2 STD MX PWR CAPT CHR PT TO &=300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0843 | PWR WC GRP 2 HVY MX PWR SLNG SEAT PT 301-450 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0848 | PWR WC GRP 3 STD SLING SEAT PT TO & = 300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0849 | PWR WC GRP 3 STD CAPTAIN CHAIR PT TO & = 300 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0850 | PWR WC GRP 3 HVY DUTY SLING SEAT PT 301-450 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0851 | PWR WC GRP 3 HVY DUTY CAPT CHAIR PT 301-450 LBS | Medi-Cal Prior Authorization List, Pg 28 Original policy |