Blue Shield of California Promise Health Plan prior authorization, page 2
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 |
|---|---|---|
| 38207 | CRYOPRESERVE STEM CELLS | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 38230 | BONE MARROW HARVEST ALLOGEN | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 38240 | TRANSPLT ALLO HCT/DONOR | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 38241 | TRANSPLT AUTOL HCT/DONOR | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 38242 | TRANSPLT ALLO LYMPHOCYTES | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 38243 | TRANSPLJ HEMATOPOIETIC BOOST | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 41899 | Unlisted procedure, dentoalveolar structures | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 44135 | INTESTINE TRANSPLNT CADAVER | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 47135 | TRANSPLANTATION OF LIVER | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 48554 | TRANSPL ALLOGRAFT PANCREAS | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 49591 | HERNIA OPEN PROCEDURES | Medi-Cal Prior Authorization List, Pg 3 Original policy |
| 49617 | HERNIA OPEN PROCEDURES | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 49621 | HERNIA OPEN PROCEDURES | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 50370 | RMVL TRANSPLANTED RNL ALGRFT | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 55867 | UNDER LAPAROSCOPIC PROCEDURES ON THE PROSTATE | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 56620 | VULVECTOMY SMPL PRTL | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 56625 | VULVECTOMY SMPL COMPL | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 56800 | PLSTC RPR INTROITUS | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 56805 | CLITOROPLASTY INTERSEX STATE | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 56810 | PRINEOPLASTY RPR PR NONOBAL SPX | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 57106 | VAGNC PRTL RMVL VAG WALL | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 57107 | VAGNC PRTL RMVL VAG WALL PARAVAG TISS | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 57110 | VAGNC COMPL RMVL VAG WALL | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 57111 | VAGNC COMPL RMVL VAG WALL PARAVAG TISS | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 57291 | CONSTJ ARTIF VAG W/O GRF | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 57292 | CONSTJ ARTIF VAG W/GRF | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 57295 | REVJ RMVL PROSTC VAG GRF VAG APPR | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 57296 | REVJ W/RMVL PROSTHETIC VAG GRF ABD APPRO | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 57335 | VAGINOPLASTY INTERSEX STATE | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 57426 | REVISION PROSTHETIC VAGINAL GRAFT LAPAROSCOPIC | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 58720 | SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 58940 | OOPHORECTOMY PRTL/TOT UNI/BI | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 70554 | MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 70555 | MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 72125 | CT CRV SPI C-MATRL | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 72126 | CT CRV SPI C+ MATRL | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 72127 | CT CRV SPI C-/C+ | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 72128 | CT THRC SPI C-MATRL | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 72129 | CT THRC SPI C+ MATRL | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 72130 | CT THRC SPI C-/C+ | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 72131 | CT LMBR SPI C-MATRL | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 72132 | CT LMBR SPI C+ MATRL | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 72133 | CT LMBR SPI C-/C+ | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 74712 | MRI FETAL SNGL/1ST GESTATION | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 75561 | CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 75565 | CARDIAC MRI FOR VELOCITY FLOW MAPPING | Medi-Cal Prior Authorization List, Pg 4 Original policy |
| 76014 | MR safety implant and/or foreign body assessment by trained clinical staff, including identification and verification of implant components from appropriate sources (eg, surgical reports, imaging reports, medical device databases, device vendors, review of prior imaging), analyzing current MR conditional status of individual components and systems, and consulting published professional guidance with written report; initial 15 minutes | Medi-Cal Prior Authorization List, Pg 5 Original policy |
| 76015 | MR safety implant and/or foreign body assessment by trained clinical staff, including identification and verification of implant components from appropriate sources (eg, surgical reports, imaging reports, medical device databases, device vendors, review of prior imaging), analyzing current MR conditional status of individual components and systems, and consulting published professional guidance with written report; each additional 30 minutes (List separately in addition to code for primary procedure) | Medi-Cal Prior Authorization List, Pg 5 Original policy |
| 76016 | MR safety determination by a physician or other qualified health care professional responsible for the safety of the MR procedure, including review of implant MR conditions for indicated MR examination, analysis of risk vs clinical benefit of performing MR examination, and determination of MR equipment, accessory equipment, and expertise required to perform examination, with written report | Medi-Cal Prior Authorization List, Pg 5 Original policy |
| 76017 | MR safety medical physics examination customization, planning and performance monitoring by medical physicist or MR safety expert, with review and analysis by physician or other qualified health care professional to prioritize and select views and imaging sequences, to tailor MR acquisition specific to restrictive requirements or artifacts associated with MR conditional implants or to mitigate risk of non-conditional implants or foreign bodies, with written report | Medi-Cal Prior Authorization List, Pg 5 Original policy |