Blue Shield of California Promise Health Plan prior authorization, page 15
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 |
|---|---|---|
| L0649 | LSO SC R POS/LAT PNL PRE OTS | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0651 | LSO SAGIT-CORNL CNTRL RIGD SHLL/PNL | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0980 | PERONEAL STRAPS PAIR PRE OTS | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L0982 | STOCKING SUP GRIPS 4 PRE OTS | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L1900 | AFO SPRNG WIRE DORSIFLX ASST CALF BAND CSTM FAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L1904 | AFO MOLDED ANKLE GAUNTLET | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L1907 | AFO SUPRAMALLEOLAR CUSTOM | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L1910 | AFO POST 1 BAR CLASP ATTCH SHOE COUNTER PRFAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L1920 | AFO SINGLE UPRT W/STATIC/ADJUSTBL STOP CSTM FAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L1932 | AFO RIGD ANT TIBL TOT CARB FIBER/EQUL MATL PRFAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L1945 | AFO MOLD PT MDL PLSTC RIGD ANT TIBL SECT CSTM | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L1950 | ANKLE FOOT ORTHOTIC SPIRAL PLASTIC CUSTOM-FAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L1960 | AFO POSTERIOR SOLID ANK PLASTIC CUSTOM FAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L1970 | AFO PLASTIC WITH ANKLE JOINT CUSTOM FABRICATED | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L1980 | AFO 1 UPRT FREE PLANTR DORSIFLX SOLID STIRUP FAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L1990 | AFO DBL UPRT PLANTR DORSIFLX SOLID STIRUP CSTM | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L2000 | KAFO 1 UPRT FREE KNEE FREE ANK SOLID STIRUP CSTM | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L2005 | KAFO ANY MATL AUTO LOCK&SWNG RLSE W/ANK JNT CSTM | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L2010 | KAFO 1 UPRT SOLID STIRUP W/O KNEE JNT CSTM FAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L2020 | KAFO DBL UPRT SOLID STIRUP THI&CALF CSTM FAB | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L2030 | KAFO DBL UPRT SOLID STIRUP W/O KNEE JNT CSTM | Medi-Cal Prior Authorization List, Pg 30 Original policy |
| L2034 | KAFO PLASTIC MED LAT ROTAT CNTRL CSTM FAB | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2035 | KAFO FULL PLSTC STAT PED W/O FREE MOT ANK PRFAB | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2036 | KAFO FULL PLASTIC DOUBLE UPRIGHT CSTM FAB | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2037 | KAFO FULL PLASTIC SINGLE UPRIGHT CUSTOM FAB | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2038 | KAFO FULL PLASTIC MX-AXIS ANKLE CUSTOM FAB | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2106 | AFO FX ORTHOTIC TIB FX CAST THERMOPLSTC CSTM FAB | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2108 | AFO FX ORTHOTIC TIB FX CAST ORTHOSIS CSTM FAB | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2114 | AFO TIBL FX ORTHOS SEMI-RIGD PRFAB W/FIT & ADJ | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2116 | AFO TIB FX ORTHOTIC RIGID PRFAB W/FIT & ADJ | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2126 | KAFO FEM FX CAST ORTHOTIC THERMOPLSTC CSTM FAB | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2128 | KAFO FX ORTHOTIC FEM FX CAST ORTHOSIS CSTM FAB | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2132 | KAFO FEM FX CAST ORTHOTIC SFT PRFAB W/FIT & ADJ | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2134 | KAFO FEM FX CAST ORTHOT SEMI-RIGD PRFAB FIT&ADJ | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2136 | KAFO FEM FX CAST ORTHOTIC RIGD PRFAB W/FIT & ADJ | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2180 | ADD LW EXTRM FX ORTHOT PLSTC SHOE INSRT ANK JNT | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2182 | ADD LOW EXTREM FX ORTHOTIC DROP LOCK KNEE JOINT | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2184 | ADD LOW EXTREM FX ORTHOTIC LTD MOTION KNEE JOINT | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2186 | ADD LW EXT FX ORTH ADJ MOT KNEE JNT LERMAN TYPE | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2188 | ADD LOW EXTREM FRACTURE ORTHOTIC QUADRILAT BRIM | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2190 | ADDITION LOW EXTREM FRACTURE ORTHOTIC WAIST BELT | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2192 | ADD LW EXT ORTHOTIC HIP JNT THI FLNGE&PELV BELT | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2200 | ADDITION LOWER EXTREMITY LTD ANK MOTION EA JOINT | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2210 | ADDITION LOWER EXTREM DORSIFLEX ASSIST EA JOINT | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2220 | ADD LW EXTRM DORSIFLX&PLANTR ASST/RSIST EA JNT | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2230 | ADD LW EXTRM SPLIT FLAT CALIPRR STIRRUPS & PLATE | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2232 | ADD LOW EXT ORTHOS ROCKR BOTTOM TOT CNTC CSTM | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2240 | ADD LOW EXTREM ROUND CALIPER&PLATE ATTACHMENT | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2250 | ADD LOW EXTREM FT PLATE MOLD PT MDL STIRUP ATTCH | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2260 | ADDITION LOWER EXTREM REINFORCED SOLID STIRRUP | Medi-Cal Prior Authorization List, Pg 31 Original policy |