Blue Shield of California Promise Health Plan prior authorization, page 19
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 |
|---|---|---|
| L5460 | IMMED POSTSURG APPLIC NONWT BEAR RIGD ABVE KNEE | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5500 | INIT BELW KNEE PTB SOCKT NON-ALIGN DIR FORMED | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5505 | INIT ABVE KNEE-DISARTC ISCH LEVL SOCKT NON-ALIGN | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5510 | PREP BELW KNEE PTB SOCKT NON-ALIGN MOLD MDL | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5520 | PREP BK PTB SCKT NON-ALIGN THERMOPLSTC/=DIR FORM | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5530 | PREP BK PTB SCKT NON-ALIGN THERMOPLSTC/=MOLD MDL | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5535 | PREP BELOW KNEE PTB NON-ALIGN PRFAB ADJ OPEN END | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5540 | PREP BK PTB SCKT NON-ALIGN LAMNATD SCKT MOLD MDL | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5560 | PREP AK-DISRTC ISCH LEVL PLASTER SOCKET MOLD MDL | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5570 | PREP AK-DISRTC ISCH LEVL THERMOPLSTC/=DIR FORMED | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5580 | PREP AK DISARTIC NON-ALIGN THERMOPLSTC/=MOLD MDL | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5585 | PREP AK-DISARTC NON-ALIGN PRFAB ADJ OPN END SCKT | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5590 | PREP AK-DISARTIC NON-ALIGN LAMINATED SCKT MOLD | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5595 | PREP HIP DISARTIC-HEMIPELVECT THERMOPLSTC/=MOLD | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5600 | PREP HIP DISARTIC-HEMIPELVECT LAMINATD SCKT MOLD | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5610 | ADD LW EXTRM ENDO SYS ABVE KNEE HYDRACADENCE SYS | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5611 | ADD LW EXTRM ENDO AK-DISRTC 4-BAR LINK W/FRICT | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5613 | ADD LW EXTRM ENDO AK-DISARTIC 4-BAR W/HYDRAULIC | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5614 | ADD LW EXT EXOSKEL SYS AK-DISARTC 4-BAR PNEUMAT | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5616 | ADD LW EXTRM ENDO AK UNIVERSAL MXPLX SYS FRICT | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5617 | ADD LW EXTRM QUICK CHG SLF-ALIGN U AK/BK EA | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5618 | ADDITION TO LOWER EXTREMITY TEST SOCKET SYMES | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5620 | ADDITION LOWER EXTREMITY TEST SOCKET BELOW KNEE | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5622 | ADDITION LOWER EXTREM TEST SOCKET KNEE DISARTIC | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5624 | ADDITION LOWER EXTREMITY TEST SOCKET ABOVE KNEE | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5626 | ADDITION LOWER EXTREM TEST SOCKET HIP DISARTIC | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5628 | ADDITION LOWER EXTREM TEST SOCKET HEMIPELVECTOMY | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5630 | ADD LOW EXTREM SYMES TYPE EXPANDABLE WALL SOCKT | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5631 | ADD LW EXT ABVE KNEE/KNEE DISARTIC ACRYLC SOCKT | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5632 | ADD LOW EXTREM SYMES TYPE PTB BRIM DESIGN SOCKT | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5634 | ADD LOW EXTREM SYMES TYPE POST OPENING SOCKT | Medi-Cal Prior Authorization List, Pg 36 Original policy |
| L5636 | ADDITION LOW EXTREM SYMES TYPE MED OPENING SOCKT | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5637 | ADDITION LOWER EXTREMITY BELOW KNEE TOTAL CNTC | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5638 | ADDITION LOWER EXTREM BELOW KNEE LEATHER SOCKET | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5639 | ADDITION LOWER EXTREMITY BELOW KNEE WOOD SOCKET | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5640 | ADDITION LOWER EXTREM KNEE DISARTIC LEATHR SOCKT | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5642 | ADDITION LOWER EXTREM ABOVE KNEE LEATHER SOCKET | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5643 | ADD LW EXT HIP DISARTIC FLX INNR SOCKT EXT FRAME | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5644 | ADDITION LOWER EXTREMITY ABOVE KNEE WOOD SOCKET | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5645 | ADD LW EXT BELW KNEE FLXIBLE INNR SOCKT EXT FRME | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5646 | ADD LOW EXT BELOW KNEE AIR FL GEL/= CUSHN SOCKT | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5647 | ADDITION LOWER EXTREM BELOW KNEE SUCTION SOCKET | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5648 | ADD LOW EXT ABOVE KNEE AIR FL GEL/= CUSHN SOCKT | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5649 | ADD LW EXT ISCHIAL CONTAINMENT/NARROW M-L SOCKET | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5650 | ADD LW EXT TOTAL CONTACT ABVE KNEE/KNEE DISARTC | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5651 | ADD LW EXT ABVE KNEE FLXIBLE INNR SOCKT EXT FRME | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5652 | ADD LW EXT SUCTN SUSP ABVE KNEE/KNEE DISARTIC | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5653 | ADD LOW EXTREM KNEE DISARTIC XPNDABLE WALL SOCKT | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5654 | ADDITION TO LOWER EXTREMITY SOCKET INSERT SYMES | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5655 | ADDITION LOWER EXTREM SOCKET INSERT BELOW KNEE | Medi-Cal Prior Authorization List, Pg 37 Original policy |