Blue Shield of California Promise Health Plan prior authorization, page 20
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 |
|---|---|---|
| L5656 | ADDITION LOWER EXTREM SOCKT INSERT KNEE DISARTIC | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5658 | ADDITION LOWER EXTREM SOCKET INSERT ABOVE KNEE | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5661 | ADD LOW EXTREM SOCKT INSERT MULTIDUROMETER SYMES | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5665 | ADD LW EXTRM SOCKT INSRT MXIDUROMETER BELW KNEE | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5666 | ADDITION LOWER EXTREM BELOW KNEE CUFF SUSPENSION | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5670 | ADD LOW EXTREM BELW KNEE MOLD SUPRACONDYLR SUSP | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5671 | ADD LW EXTRM BELW/ABVE KNEE SUSP LOCK MECH | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5672 | ADD LOW EXTREM BELOW KNEE REMV MED BRIM SUSP | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5673 | ADD LW EXT CSTM MOLD/PRFAB FOR USE W/LOCK MECH | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5676 | ADD LOW EXTREM BELW KNEE KNEE JNT 1 AXIS PAIR | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5677 | ADD LOW EXTREM BELW KNEE KNEE JNT POLYCNTRC PAIR | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5678 | ADDITION LOW EXTREM BELOW KNEE JOINT COVERS PAIR | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5679 | ADD LW EXT BK/AK CSTM MOLD/PRFAB NOT W/LOCK MECH | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5680 | ADD LOW EXTREM BELOW KNEE THIGH LACER NONMOLDED | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5681 | ADD LW EXT CSTM INSRT CNGN/ATYP TRAUMAT AMP INIT | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5682 | ADD LW EXTRM BELW KNEE THI LACER GLUTL/ISCH MOLD | Medi-Cal Prior Authorization List, Pg 37 Original policy |
| L5683 | ADD LW EXT CSTM INSRT NO CNGN/TRAUMAT AMP INIT | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5684 | ADDITION LOWER EXTREMITY BELOW KNEE FORK STRAP | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5685 | ADD LOW EXT PROS BELW KNEE SUSP/SEAL SLEEVE EA | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5686 | ADDITION LOWER EXTREMITY BELOW KNEE BACK CHECK | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5688 | ADD LOW EXTREM BELOW KNEE WAIST BELT WEBBING | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5690 | ADD LOW EXTREM BELOW KNEE WAIST BELT PADD&LINED | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5692 | ADD LOW EXTREM ABVE KNEE PELV CONTROL BELT LIGHT | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5694 | ADD LOW EXTREM ABVE KNEE PELV CNTRL BELT PADD&LN | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5695 | ADD LW EXTRM ABVE KNEE PELV CNTRL SLV NEOPRENE | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5696 | ADD LOW EXTREM ABVE KNEE/KNEE DISARTIC PELV JNT | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5697 | ADD LOW EXTREM ABVE KNEE/KNEE DISARTIC PELV BAND | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5698 | ADD LW EXTRM AK/KNEE DISRTC SILESIAN BANDGE | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5699 | ALL LOWER EXTREMITY PROSTHESES SHOULDER HARNESS | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5700 | REPLACEMENT SOCKET BELOW KNEE MOLDED PT MODEL | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5701 | REPL SOCKT ABVE KNEE/KNEE DISARTIC W/ATTCH PLAT | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5702 | REPLCMT SOCKT HIP DISARTIC W/HIP JNT MOLD PT MDL | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5703 | ANKLE SYMES MOLD PT MODEL SACH FOOT REPL ONLY | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5704 | CUSTOM SHAPED PROTECTIVE COVER BELOW KNEE | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5705 | CUSTOM SHAPED PROTECTIVE COVER ABOVE KNEE | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5706 | CUSTOM SHAPED PROTECTIVE COVER KNEE DISARTIC | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5707 | CUSTOM SHAPED PROTECTIVE COVER HIP DISARTIC | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5710 | ADD EXOSKEL KNEE-SHIN SYSTEM 1 AXIS MANUAL LOCK | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5711 | ADD EXOSKEL KNEE-SHIN 1 AXIS MNL LOCK ULTRA-LGHT | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5712 | ADD EXOSKEL KNEE-SHIN 1 AXIS FRICT SWING CNTRL | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5714 | ADD EXOSKEL KNEE-SHIN VARIBL FRICT SWING CNTRL | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5716 | ADD EXOSKEL KNEE-SHIN POLYCNTRC MECH STANCE LOCK | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5718 | ADD EXOSKL KNEE-SHIN POLYCNTRC FRICT SWING CNTRL | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5722 | ADD EXOSKEL KNEE-SHIN PNEUMAT SWING FRICT CNTRL | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5724 | ADD EXOSKEL KNEE-SHIN FLUID SWING PHASE CNTRL | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5726 | ADD EXOSKEL KNEE-SHIN EXT JOINT FL SWING CNTRL | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5728 | ADD EXOSKEL KNEE-SHIN FLUID SWING&STANCE CNTRL | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5780 | ADD EXOSKL KNEE-SHIN PNEUMAT/HYDRA PNEUMAT CNTRL | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5781 | ADD LW LIMB PROS RESIDUL LIMB VOL MGMT SYS | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5782 | ADD LW LIMB PROS RESIDUL LIMB MGMT SYS HEVY DUTY | Medi-Cal Prior Authorization List, Pg 38 Original policy |