Blue Shield of California Promise Health Plan prior authorization, page 17
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 |
|---|---|---|
| L3201 | ORTHOPED SHOE OXFORD W/SUPINATOR/PRONATOR INFNT | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3202 | ORTHOPED SHOE OXFORD W/SUPINATOR/PRONATOR CHILD | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3203 | ORTHOPEDIC SHOE OXFORD W/SUPINATOR/PRONATOR JR | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3204 | ORTHOPED SHOE HIGHTOP W/SUPINATOR/PRONATOR INFNT | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3206 | ORTHOPED SHOE HIGHTOP W/SUPINATOR/PRONATOR CHILD | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3207 | ORTHOPEDIC SHOE HIGHTOP W/SUPINATOR/PRONATOR JR | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3215 | ORTHOPEDIC FOOTWEAR LADIES SHOE OXFORD EACH | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3217 | ORTHOPED FTWEAR LADIES SHOE HITOP DEPTH INLAY EA | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3219 | ORTHOPEDIC FOOTWEAR MENS SHOE OXFORD EACH | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3222 | ORTHOPED FOOTWEAR MENS SHOE HITOP DEPTH INLAY EA | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3230 | ORTHOPEDIC FOOTWEAR CUSTOM SHOE DEPTH INLAY EACH | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3250 | ORTHOPED FTWEAR CSTM MOLD REMV INNR MOLD PROSTH | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3251 | FOOT SHOE MOLDED PATIENT MODEL SILICONE SHOE EA | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3252 | FOOT SHOE MOLDED PT MDL PLASTAZOTE CSTM FABR EA | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3253 | FOOT MOLDED SHOE PLASTAZOTE CUSTOM FITTED EACH | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3254 | NONSTANDARD SIZE OR WIDTH | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3255 | NONSTANDARD SIZE OR LENGTH | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3257 | ORTHOPEDIC FOOTWEAR ADDITIONAL CHARGE SPLIT SIZE | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3265 | PLASTAZOTE SANDAL EACH | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3330 | LIFT ELEVATION METAL EXTENSION | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3334 | LIFT ELEVATION HEEL PER INCH | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3340 | HEEL WEDGE SACH | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3360 | SOLE WEDGE OUTSIDE SOLE | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3370 | SOLE WEDGE BETWEEN SOLE | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3380 | CLUBFOOT WEDGE | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3390 | OUTFLARE WEDGE | Medi-Cal Prior Authorization List, Pg 33 Original policy |
| L3400 | METATARSAL BAR WEDGE ROCKER | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3410 | METATARSAL BAR WEDGE BETWEEN SOLE | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3420 | FULL SOLE AND HEEL WEDGE BETWEEN SOLE | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3430 | HEEL COUNTER PLASTIC REINFORCED | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3440 | HEEL COUNTER LEATHER REINFORCED | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3450 | HEEL SACH CUSHION TYPE | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3455 | HEEL NEW LEATHER STANDARD | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3460 | HEEL NEW RUBBER STANDARD | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3465 | HEEL THOMAS WITH WEDGE | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3470 | HEEL THOMAS EXTENDED TO BALL | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3480 | HEEL PAD AND DEPRESSION FOR SPUR | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3485 | HEEL PAD REMOVABLE FOR SPUR | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3500 | ORTHOPEDIC SHOE ADDITION INSOLE LEATHER | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3510 | ORTHOPEDIC SHOE ADDITION INSOLE RUBBER | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3520 | ORTHOPED SHOE ADDITION INSOLE FELT COVR W/LEATHR | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3530 | ORTHOPEDIC SHOE ADDITION SOLE HALF | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3540 | ORTHOPEDIC SHOE ADDITION SOLE FULL | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3550 | ORTHOPEDIC SHOE ADDITION TOE TAP STANDARD | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3560 | ORTHOPEDIC SHOE ADDITION TOE TAP HORSESHOE | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3570 | ORTHOPEDIC SHOE ADDITION SPECIAL EXT INSTEP | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3580 | ORTHOPED SHOE ADD CONVERT INSTEP VELCRO CLOS | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3590 | ORTHO SHOE ADD CONVRT FIRM COUNTER SFT COUNTER | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3595 | ORTHOPEDIC SHOE ADDITION MARCH BAR | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3600 | TRNSF ER ORTHOTIC SHOE TO SHOE CALIPR PLAT XST | Medi-Cal Prior Authorization List, Pg 34 Original policy |