Blue Shield of California Promise Health Plan prior authorization, page 18
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 |
|---|---|---|
| L3610 | TRNSF ORTHOT ONE SHOE TO ANOTHER CALIP PLATE NEW | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3620 | TRNSF ORTHOT 1 SHOE-ANOTHR SOLID STIRRUP EXIST | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3630 | TRNSF ORTHOS 1 SHOE TO ANOTHER SOLID STIRRUP NEW | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L3640 | TRNSF ORTHOT SHOE TO SHOE DENNIS BROWNE SPLNT | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L4002 | REPL STRAP ANY ORTHOTIC ALL CMPNTS ANY LEN TYPE | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L4010 | REPLACE TRILATERAL SOCKET BRIM | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L4020 | REPLACE QUADRILAT SOCKET BRIM MOLDED PT MODEL | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L4030 | REPLACE QUADRILATERAL SOCKET BRIM CUSTOM FITTED | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L4040 | REPLACE MOLDED THI LACER CSTM FAB ORTHOTIC ONLY | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L4045 | REPLACE NONMOLD THI LACER CSTM FAB ORTHOSIS ONLY | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L4050 | REPLACE MOLDED CALF LACER CSTM FAB ORTHOTIC ONLY | Medi-Cal Prior Authorization List, Pg 34 Original policy |
| L4055 | REPLACE NONMOLD CALF LACER CSTM FAB ORTHOS ONLY | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L4060 | REPLACE HIGH ROLL CUFF | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L4070 | REPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFO | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L4080 | REPLACE METAL BANDS KAFO PROXIMAL THIGH | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L4090 | REPLACE METAL BANDS KAFO-AFO CALF/DISTAL THIGH | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L4100 | REPLACE LEATHER CUFF KAFO PROXIMAL THIGH | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L4110 | REPLACE LEATHER CUFF KAFO-AFO CALF/DISTAL THIGH | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L4130 | REPLACE PRETIBIAL SHELL | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L4205 | REPAIR ORTHOTIC DEVC LABOR COMPONENT PER 15 MIN | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L4210 | REPAIR ORTHOTIC DEVC REPAIR/REPLACE MINOR PARTS | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L4350 | ANKLE CONTROL ORTHO PRE OTS | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L4370 | PNEUM FULL LEG SPLNT PRE OTS | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L4398 | FOOT DROP SPLINT PRE OTS | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L4631 | AFO WALK BOOT TYP ROCKR BOTTM ANT TIB SHELL CSTM | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5010 | PARTIAL FT MOLDED SOCKET ANK HEIGHT W/TOE FILLER | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5020 | PART FT MOLDED SOCKET TIB TUBERCLE HT W/TOE FIL | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5050 | ANKLE SYMES MOLDED SOCKET SACH FOOT | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5060 | ANK SYMES METL FRME MOLD LEATHR SOCKT ARTIC ANK | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5100 | BELOW KNEE MOLDED SOCKET SHIN SACH FOOT | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5105 | BELOW KNEE PLSTC SOCKT JNT&THIGH LACER SACH FOOT | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5150 | KNEE DISRTC MOLD SOCKT EXT KNEE JNT SHIN SACH FT | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5160 | KNEE DISARTIC MOLD SOCKT BENT KNEE EXT KNEE JNT | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5200 | ABVE KNEE MOLD SOCKT 1 AXIS CONSTANT FRICTION | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5210 | ABVE KNEE SHRT PROSTH NO KNEE JNT NO ANK JNT EA | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5220 | ABVE KNEE SHRT PROSTH W/ARTIC ANK/FOOT DYN | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5230 | ABVE KNEE PROX FEM FOCAL DEFIC SACH FOOT | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5250 | HIP DISARTIC CANADIAN TYPE; MOLD SOCKT HIP JNT | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5270 | HIP DISRTC TILT TABLE; MOLD SCKT LOCK HIP JNT | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5280 | HEMIPELVECT CANADIAN TYPE; MOLD SOCKT HIP JNT | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5301 | BELW KNEE MOLD SOCKT SHIN SACH FT ENDOSKEL SYS | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5312 | KNEE DISART MOLD SOCKET 1 AXIS KNEE | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5321 | ABOVE KNEE OPEN END SACH FT ENDO SYS 1 AXIS KNEE | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5331 | JOINT SINGLE AXIS KNEE SACH FOOT | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5341 | SINGLE AXIS KNEE SACH FOOT | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5400 | IMMED POSTSURG/ERLY FIT APPLY RIGD DRESS W/1 CHG | Medi-Cal Prior Authorization List, Pg 35 Original policy |
| L5410 | IMMED POSTSURG APPL RIGD DRESS W/EA ADD CAST CHG | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5420 | IMMED POSTSURG INIT RIGD DRESS 1 CHG AK/KNEE | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5430 | IMMED POSTSURG INIT RIGD DRSG AK EA ADD CAST CHG | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5450 | IMMED POSTSURG APPLIC NONWT BEAR RIGD BELW KNEE | Medi-Cal Prior Authorization List, Pg 36 Original policy |