Blue Shield of California Promise Health Plan prior authorization, page 16
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 |
|---|---|---|
| L2265 | ADDITION TO LOWER EXTREMITY LONG TONGUE STIRRUP | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2270 | ADD LW EXT VARUS/VALGUS CORR STRAP PAD/LINE PAD | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2275 | ADD LW EXTRM VARUS/VULGUS CORR PLSTC MOD PADD/LN | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2280 | ADDITION TO LOWER EXTREMITY MOLDED INNER BOOT | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2300 | ADDITION LOW EXTREM ABDUCT BAR JOINTED ADJUSTBLE | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2310 | ADDITION LOWER EXTREMITY ABDUCTION BAR STRAIGHT | Medi-Cal Prior Authorization List, Pg 31 Original policy |
| L2320 | ADD LOW EXT NONMOLD LACER CSTM FAB ORTHOS ONLY | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2330 | ADD LOW EXT LACER MOLD PT MDL CSTM ORTHOTIC ONLY | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2335 | ADDITION TO LOWER EXTREMITY ANTERIOR SWING BAND | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2340 | ADD LOW EXTREM PRETIBL SHELL MOLDED PT MODEL | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2350 | ADD LOW EXTREM PROSTHETIC TYPE SOCKT MOLD PT MDL | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2360 | ADDITION TO LOWER EXTREMITY EXTENDED STEEL SHANK | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2370 | ADDITION TO LOWER EXTREMITY PATTEN BOTTOM | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2375 | ADD LW EXT TORSION CNTRL ANK JNT&HALF STIRUP | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2380 | ADD LW EXT TORSION CNTRL STRAIT KNEE JNT EA JNT | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2385 | ADD LOW EXTREM STRAIT KNEE JNT HEVY DUTY EA JNT | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2387 | ADD LW EXT POLYCENTRIC KNEE JNT CSTM KAFO EA JNT | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2390 | ADDITION LOWER EXTREM OFFSET KNEE JOINT EA JOINT | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2395 | ADD LOW EXTREM OFFSET KNEE JNT HEVY DUTY EA JNT | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2397 | ADDITION LOWER EXTREM ORTHOTIC SUSPENSION SLEEVE | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2405 | ADDITION TO KNEE JOINT DROP LOCK EACH | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2415 | ADD KNEE LOCK W/INTEGRATED RLSE MECH MATL EA JNT | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2425 | ADD KNEE JNT DISC/DIAL LOCK ADJ KNEE FLX EA JNT | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2430 | ADD KNEE JNT RATCHET LOCK KNEE EXT EA JNT | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2492 | ADDITION TO KNEE JOINT LIFT LOOP DROP LOCK RING | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2500 | ADD LW EXTRM THI/WT BEAR GLUTL/ISCH WT BEAR RING | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2510 | ADD LW EXTRM THI/WT BEAR QUADRI-LAT BRIM MOLD PT | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2520 | ADD LW EXTRM THI/WT BEAR QUADRI-LAT BRIM CSTM | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2525 | ADD LW EXTRM ISCH M-L BRIM MOLD PT MDL | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2526 | ADD LW EXTRM ISCH M-L BRIM CSTM FIT | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2530 | ADD LOW EXTREM THIGH/WEIGHT BEAR LACER NONMOLDED | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2540 | ADD LOW EXTREM THI/WEIGHT BEAR LACER MOLD PT MDL | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2550 | ADD LOW EXTREM THIGH/WEIGHT BEAR HIGH ROLL CUFF | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2750 | ADD LOW EXTREM ORTHOTIC PLATING CHROME/NICKL-BAR | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2755 | ADD LOW EXT ORTHOTIC HYBRID COMPOS PER SEG CSTM | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2760 | ADDITION LOW EXTREM ORTHOTIC EXT PER EXT PER BAR | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2768 | ORTHOTIC SIDE BAR DISCONNECT DEVICE PER BAR | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2780 | ADD LOW EXTREM ORTHOTIC NONCORROSIVE FINISH BAR | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2785 | ADDITION LOW EXTREM ORTHOTIC DROP LOCK RETAIN EA | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2795 | ADD LOW EXTREM ORTHOTIC KNEE CNTRL FULL KNEECAP | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2800 | ADD LOW EXT ORTHOT KNEE CNTRL KNEE CAP CSTM ONLY | Medi-Cal Prior Authorization List, Pg 32 Original policy |
| L2810 | ADD LOW EXTREM ORTHOTIC KNEE CONTROL CONDYLR PAD | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L2820 | ADD LW EXT ORTH SFT INTERFCE MOLD BELW KNEE | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L2830 | ADD LW EXT ORTHOTIC SOFT INTERFCE MOLD ABVE KNEE | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L2840 | ADD LOW EXTREM ORTHOTIC TIB LENGTH SOCK FX/= EA | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L2850 | ADD LOW EXTREM ORTHOT FEM LENGTH SOCK FX/EQUL EA | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3100 | HALLUS-VALGUS NT DYN PRE OTS | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3140 | FOOT ABDUCTION ROTATION BAR INCLUDING SHOES | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3150 | FOOT ABDUCTION ROTATION BAR WITHOUT SHOES | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3160 | FOOT ADJUSTABLE SHOE-STYLED POSITIONING DEVICE | Medi-Cal Prior Authorization List, Pg 33 Original policy |