Blue Shield of California Promise Health Plan prior authorization, page 14
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 |
|---|---|---|
| K0852 | PWR WC GRP 3 V HVY DUTY SLING SEAT PT 451-600 LB | Medi-Cal Prior Authorization List, Pg 28 Original policy |
| K0853 | PWR WC GRP 3 HVY DUTY CAPT CHAIR PT 451-600 LBS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0854 | PWR WC GRP 3 XTRA HVY DTY SLNG SEAT PT 601 LBS/> | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0855 | PWR WC GRP 3X HVY DTY CHR PT WT CAP 601 LB/> | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0856 | PWR WC GRP 3 STD 1 PWR SLING SEAT PT TO &=300 LB | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0857 | PWR WC GRP 3 STD 1 PWR CAPT CHAIR PT TO &=300 LB | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0858 | PWR WC GRP 3 HD 1 PWR SLING SEAT PT 301-450 LBS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0859 | PWR WC GRP 3 HD 1 PWR CAPT CHAIR PT 301-450 LBS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0860 | PWR WC GRP 3 V HD 1 PWR SLING SEAT PT 451-600 LB | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0861 | PWR WC GRP 3 STD MX PWR SLNG SEAT PT TO &=300 LB | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0862 | PWR WC GRP 3 HD MX PWR SLING SEAT PT 301-450 LBS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0863 | PWR WC GRP 3 V HD MX PWR SLNG SEAT PT 451-600 LB | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0864 | PWR WC GRP 3 XTR HD MX PWR SLNG SEAT PT 601 LB/> | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0868 | PWR WC GRP 4 STD SLING SEAT PT TO & = 300 LBS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0869 | PWR WC GRP 4 STD CAPTAIN CHAIR PT TO & = 300 LBS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0870 | PWR WC GRP 4 HVY DUTY SLING SEAT PT 301-450 LBS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0871 | PWR WC GRP 4 V HVY DUTY SLING SEAT PT 451-600 LB | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0877 | PWR WC GRP 4 STD 1 PWR SLING SEAT PT TO &=300 LB | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0878 | PWR WC GRP 4 STD 1 PWR CAPT CHAIR PT TO &=300 LB | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0879 | PWR WC GRP 4 HD 1 PWR SLING SEAT PT 301-450 LBS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0880 | PWR WC GRP 4 V HD 1 PWR SLING SEAT PT 451-600 LB | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0884 | PWR WC GRP 4 STD MX PWR SLNG SEAT PT TO &=300 LB | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0885 | PWR WC GRP 4 STD MX PWR CAPT CHR PT TO &=300 LBS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0886 | PWR WC GRP 4 HD MX PWR SLING SEAT PT 301-450 LBS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0890 | PWR WC GRP 5 PED 1 PWR SLING SEAT PT TO &=125 LB | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0891 | PWR WC GRP 5 PED MX PWR SLNG SEAT PT TO &=125 LB | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| K0898 | POWER WHEELCHAIR NOT OTHERWISE CLASSIFIED | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| L0150 | CERVICAL SEMI-RIGID ADJUSTABLE MOLDED CHIN CUP | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| L0160 | CERV SR WIRE OCC/MAN PRE OTS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| L0172 | CERV COL SR FOAM 2PC PRE OTS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| L0621 | SIO FLEX PELVIC/SACR PRE OTS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| L0622 | SACROILIAC ORTHOTIC FLEXIBLE CUSTOM FABRICATED | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| L0623 | SIO RIG PNL PELV/SAC PRE OTS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| L0624 | SACROIL ORTHOT W/ RIGD/SEMI-RIGD PANELS CSTM FAB | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| L0625 | LO FLEX L1-BELOW L5 PRE OTS | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| L0626 | LO SAG RIG PNL STAYS PRE CST | Medi-Cal Prior Authorization List, Pg 29 Original policy |
| L0628 | LSO FLEX NO RI STAYS PRE OTS | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0629 | LUMBAR-SACRAL ORTHOTIC FLEXIBLE CUSTOM FAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0630 | LSO R POST PNL SJ-T9 PRE CST | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0632 | LUMBAR-SACR ORTHOT W/RIGD ANT&POST PANL CSTM FAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0633 | LSO SC R POS/LAT PNL PRE CST | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0634 | LUMBAR-SAC ORTHOT RIGD POST FRAME/PANL CSTM FAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0635 | LSO LUMB FLEX RIGD POST FRAME/PANL PREFAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0636 | LSO LUMB FLEX RIGD POST FRAME/PANL CSTM FAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0638 | LSO W/RIGID ANT & POST FRAME/PANEL CUSTOM FAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0639 | LSO S/C SHELL/PANEL PREFAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0640 | LUMBAR-SACRAL ORTHOT RIGID SHELL/PANEL CSTM FAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0641 | LO RIG POS PNL L1-L5 PRE OTS | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0643 | LSO SAG CTR RIGI POS PRE OTS | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0648 | LSO SAG R AN/POS PNL PRE OTS | Medi-Cal Prior Authorization List, Pg 30 Original policy |