Blue Shield of California Promise Health Plan prior authorization, page 23
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 |
|---|---|---|
| Q4377 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4378 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4379 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4380 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4382 | AmnioCore SL, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4383 | Axolotl Graft Ultra, per sq cm | Medi-Cal Prior Authorization List, Pg 41 Original policy |
| Q4384 | Axolotl DualGraft Ultra, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4385 | Apollo FT, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4386 | Acesso TrifACA, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4387 | NeoThelium FT, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4388 | NeoThelium 4L, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4389 | NeoThelium 4L Plus, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4390 | Ascendion, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4391 | AmnioPlast Double, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4392 | GRAFIX Duo, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4393 | SurGraft AC, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4394 | SurGraft ACA, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4395 | Acelagraft, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4396 | Natalin, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4397 | Summit AAA, per sq cm | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4418 | BioLab Membrane Wrap Flow, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4419 | BioLab Membrane Wrap Lite Flow, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4421 | BioLab Membrane Wrap Solo, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4422 | A/C Wrap, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4423 | BioLab Tri-Membrane Wrap Flow, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4424 | Revive FT, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4425 | Revive TL, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4426 | DermaBind TL + or DermaBind TL X, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4427 | DermaBind DL N, DermaBind DL +, or DermaBind DL X, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4428 | DermaBind SL N, DermaBind SL +, or DermaBind SL X, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4429 | DermaBind CH N or DermaBind CH X, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4435 | Renati Membrane, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 42 Original policy |
| Q4436 | Renati AC Membrane, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 43 Original policy |
| Q4437 | Revival AC, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 43 Original policy |
| Q4438 | Pretect, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 43 Original policy |
| Q4439 | InstaGraft, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 43 Original policy |
| Q4440 | CuraMatrix, per sq cm (add-on, list separately in addition to primary procedure) | Medi-Cal Prior Authorization List, Pg 43 Original policy |
| S4024 | Air polymer-type A intrauterine foam, per study dose | Medi-Cal Prior Authorization List, Pg 43 Original policy |
| S5102 | Air polymer-type A intrauterine foam, per study dose | Medi-Cal Prior Authorization List, Pg 43 Original policy |
| S5111 | HOME CARE TRAINING FAMILY; PER SESSION | Medi-Cal Prior Authorization List, Pg 43 Original policy |
| S8035 | MAGNETIC SOURCE IMAGING | Medi-Cal Prior Authorization List, Pg 43 Original policy |
| T1016 | CASE MANAGEMENT EACH 15 MINS | Medi-Cal Prior Authorization List, Pg 43 Original policy |
| T1023 | CASE MANAGEMENT EACH 15 MINS | Medi-Cal Prior Authorization List, Pg 43 Original policy |
| T2045 | Hospice Inpatient Care, Per Diem | Medi-Cal Prior Authorization List, Pg 43 Original policy |
| J0222 | Patisiran (Onpattro) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0223 | Givosiran (Givlaari) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0224 | Lumasiran (Oxlumo) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0225 | Vutrisiran (Amvuttra) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0364 | Apomorphine (Apokyn) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0485 | Belatacept (Nulojix) | Medi-Cal Prior Authorization List, Pg 44 Original policy |