Blue Shield of California Promise Health Plan prior authorization, page 21
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 |
|---|---|---|
| L5785 | ADD EXOSKEL SYSTEM BELW KNEE ULTRA-LGHT MATERIAL | Medi-Cal Prior Authorization List, Pg 38 Original policy |
| L5790 | ADD EXOSKEL SYSTEM ABVE KNEE ULTRA-LGHT MATERIAL | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5795 | ADD EXOSKEL SYSTEM HIP DISARTIC ULTRA-LGHT MATL | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5810 | ADD ENDOSKEL KNEE-SHIN SYSTEM 1 AXIS MANUAL LOCK | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5811 | ADD ENDOSKEL KNEE-SHIN MNL LOCK ULTRA-LGHT MATL | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5812 | ADD ENDOSKEL KNEE-SHIN FRICT SWING&STANCE CNTRL | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5814 | ADD ENDOSKEL KNEE-SHIN HYDRAULIC SWING MECH LOCK | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5816 | ADD ENDOSKEL KNEE-SHIN MECH STANCE PHASE LOCK | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5818 | ADD ENDOSKEL KNEE-SHIN FRICT SWING&STANCE CNTRL | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5822 | ADD ENDOSKEL KNEE-SHIN PNEUMAT SWING FRICT CNTRL | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5824 | ADD ENDOSKEL KNEE-SHIN FLUID SWING PHASE CNTRL | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5826 | ADD ENDO KNEE-SHIN HYDRAUL SWNG MIN HI ACTV FRME | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5828 | ADD ENDO KNEE-SHIN FL SWING&STANCE PHASE CNTRL | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5830 | ADD ENDOSKEL KNEE-SHIN PNEUMAT/SWING PHASE CNTRL | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5840 | ADD ENDO KNEE-SHIN 4-BAR LINK/MX-AXIAL PNEUMAT | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5845 | ADD ENDOSKEL KNEE-SHIN STANCE FLX FEATUR ADJ | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5848 | ADD ENDOSKEL KNEE-SHIN SYS FLUID STANCE EXTENSN | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5850 | ADD ENDOSKEL SYS AK/HIP DISARTIC KNEE EXT ASST | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5855 | ADD ENDOSKEL SYS HIP DISARTIC MECH HIP EXT ASST | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5856 | ADD LOW EXT PROS KNEE-SHIN SYS SWING&STANCE PHSE | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5857 | ADD LOW EXT PROS KNEE-SHIN SYS SWING PHASE ONLY | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5858 | ADD LW EXT PROS KNEE SHIN SYS STANCE PHASE ONLY | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5859 | Knee-shin pro flex/ext cont | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5910 | ADD ENDOSKEL SYSTEM BELOW KNEE ALIGNABLE SYSTEM | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5920 | ADD ENDOSKEL SYS AK/HIP DISARTIC ALIGNABLE SYS | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5925 | ADD ENDOSKEL AK-DISARTIC/HIP DISARTIC MNL LOCK | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5930 | ADD ENDOSKEL SYSTEM HIGH ACTV KNEE CONTROL FRAME | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5940 | ADD ENDOSKEL SYSTEM BELW KNEE ULTRA-LGHT MATL | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5950 | ADD ENDOSKEL SYSTEM ABVE KNEE ULTRA-LGHT MATL | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5960 | ADD ENDOSKEL SYSTEM HIP DISARTIC ULTRA-LGHT MATL | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5961 | ADD ENDO SYS POLYCNTRC HIP JOINT ROTATION CNTRL | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5962 | ADD ENDOSKEL BK FLXIBLE PROTVE OUTR SURF COVRING | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5964 | ADD ENDOSKEL AK FLXIBLE PROTVE OUTR SURF COVR | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5966 | ADD ENDO HIP DISRTC FLXIBL PROTVE OUTR SURF COVR | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5968 | ADD LW LIMB PROSTH MX-AXIAL ANK W/SWING PHASE | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5970 | ALL LOW EXTREM PROSTH FT EXTERNAL KEEL SACH FOOT | Medi-Cal Prior Authorization List, Pg 39 Original policy |
| L5971 | ALL LOWER EXTREM PROS SACH FOOT REPLACEMENT ONLY | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L5973 | ENDOSKEL ANK FOOT SYS MICRPROCSS CONTROL PWR SRC | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L5974 | ALL LOWER EXTREM PROSTH FT SINGLE AXIS ANK/FOOT | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L5975 | ALL LW EXTRM PRSTH COMB 1 AXIS ANK&FLXBL KEEL FT | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L5976 | ALL LOWER EXTREM PROSTHESES ENERGY STORING FOOT | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L5978 | ALL LOWER EXTREM PROSTH FT MULTI-AXIAL ANK/FOOT | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L5979 | ALL LW EXTRM PRSTH MX-AXL ANK DYN RSPN FT 1 PECE | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L5980 | ALL LOWER EXTREMITY PROSTHESES FLEX-FOOT SYSTEM | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L5981 | ALL LOWER EXTREM PROSTH FLEX-WALK SYSTEM/EQUAL | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L5982 | ALL EXOSKEL LOW EXTREM PROSTH AXIAL ROTAT UNIT | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L5985 | ALL ENDOSKEL LOW EXTREM PROSTH DYN PROSTH PYLN | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L5986 | ALL LOW EXTREM PROSTH MULTI-AXIAL ROTATION UNIT | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L5987 | ALL LW XTRM PRSTH SHNK FT SYS W/VRTCL LOAD PYLN | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L5988 | ADD LW LIMB PROSTH VERTCL SHOCK RDUC PYLN FEATUR | Medi-Cal Prior Authorization List, Pg 40 Original policy |