Blue Shield of California Promise Health Plan prior authorization, page 22
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 |
|---|---|---|
| L5990 | ADD LOW EXTREM PROSTH USER ADJUSTBLE HEEL HT | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L6895 | ADD UP EXT PROSTH GLOV TERM DEVC MATL CSTM FAB | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L7510 | REPR PROSTHETIC DEVICE REPR/REPLACE MINOR PARTS | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L7520 | REPAIR PROSTHETIC DEVICE LABOR CMPNT PER 15 MIN | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L7700 | PROS SOC INSERT GASKET SEAL | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| L9900 | ORTHO&PROS SPL ACSS&/SRVC CMPNT OTH HCPCS L CODE | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4133 | Grafix Prime, Per Centimer Sq | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4272 | Esano A, per sq cm | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4273 | Esano AAA, per sq cm | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4274 | Esano AC, per sq cm | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4275 | Esano ACA, per sq cm | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4276 | ORION, per sq cm | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4278 | EPIEFFECT, per sq cm | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4280 | Xcell Amnio Matrix, per sq cm | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4281 | Barrera SL or Barrera DL, per sq cm. | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4282 | Cygnus Dual, per sq cm | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4283 | Biovance Tri-Layer or Biovance 3L, per sq cm | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4284 | DermaBind SL, per sq cm | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4285 | NuDYN DL or NuDYN DL MESH, per sq cm | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4286 | NuDYN SL or NuDYN SLW, per sq cm | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4346 | Shelter DM Matrix, per sq cm | Medi-Cal Prior Authorization List, Pg 40 Original policy |
| Q4347 | Rampart DL Matrix, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4348 | Sentry SL Matrix, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4349 | Mantle DL Matrix, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4350 | Palisade DM Matrix, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4351 | Enclose TL Matrix, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4352 | Overlay SL Matrix, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4353 | Xceed TL Matrix, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4354 | PalinGen Dual-Layer Membrane, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4355 | Abiomend Xplus Membrane and Abiomend Xplus Hydromembrane, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4356 | Abiomend Membrane and Abiomend Hydromembrane, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4357 | XWRAP Plus, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4358 | XWRAP Dual, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4359 | ChoriPly, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4360 | AmchoPlast FD, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4361 | EPIXPRESS, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4362 | CYGNUS Disk, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4363 | Amnio Burgeon Membrane and Hydromembrane, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4364 | Amnio Burgeon Xplus Membrane and Xplus Hydromembrane, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4365 | Amnio Burgeon Dual-Layer Membrane, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4366 | Dual Layer Amnio Burgeon X-Membrane, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4367 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4368 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4369 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4370 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4371 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4372 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4373 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4375 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4376 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |