Blue Shield of California Promise Health Plan prior authorization, page 8
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 |
|---|---|---|
| 0907T | Concurrent optical and magnetic stimulation (COMS) therapy, wound assessment and dressing care; each additional application, total wound(s) surface area less than or equal to 50 sq cm (List separately in addition to code for primary procedure) | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0944T | 3D contour simulation of target liver lesion(s) and margin(s) for image-guided percutaneous microwave ablation | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0946T | Orthopedic implant movement analysis using paired computed tomography (CT) examination of the target structure, including data acquisition, data preparation and transmission, interpretation and report (including CT scan of the joint or extremity performed with paired views) | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| 0947T | Magnetic resonance image guided low intensity focused ultrasound (MRgFUS), stereotactic blood-brain barrier disruption using microbubble resonators to increase the concentration of blood-based biomarkers of target, intracranial, including stereotactic navigation and frame placement, when performed | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| 0951T | Magnetic resonance image guided low intensity focused ultrasound (MRgFUS), stereotactic blood-brain barrier disruption using microbubble resonators to increase the concentration of blood-based biomarkers of target, intracranial, including stereotactic navigation and frame placement, when performed | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| 0952T | Magnetic resonance image guided low intensity focused ultrasound (MRgFUS), stereotactic blood-brain barrier disruption using microbubble resonators to increase the concentration of blood-based biomarkers of target, intracranial, including stereotactic navigation and frame placement, when performed | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| 0953T | Magnetic resonance image guided low intensity focused ultrasound (MRgFUS), stereotactic blood-brain barrier disruption using microbubble resonators to increase the concentration of blood-based biomarkers of target, intracranial, including stereotactic navigation and frame placement, when performed | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| 0954T | Magnetic resonance image guided low intensity focused ultrasound (MRgFUS), stereotactic blood-brain barrier disruption using microbubble resonators to increase the concentration of blood-based biomarkers of target, intracranial, including stereotactic navigation and frame placement, when performed | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| 0955T | Magnetic resonance image guided low intensity focused ultrasound (MRgFUS), stereotactic blood-brain barrier disruption using microbubble resonators to increase the concentration of blood-based biomarkers of target, intracranial, including stereotactic navigation and frame placement, when performed | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2030 | Miro3D Fibers, per mg | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2031 | MiroDry Wound Matrix, per sq cm | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2032 | Myriad Matrix, per sq cm | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2033 | Myriad Morcells, 4 mg | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2034 | Foundation DRS Solo, per sq cm | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2035 | Corplex P or Theracor P or Allacor P, per mg | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2036 | Cohealyx Collagen Dermal Matrix, per sq cm | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2037 | G4Derm Plus, per ml | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2038 | MariGen Pacto, per sq cm | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2039 | InnovaMatrix FD, per sq cm | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2040 | Microlyte PainGuard, per sq cm | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2041 | Foundation DRS+ Duo, per sq cm | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2042 | Foundation DRS+ Solo, per sq cm | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2043 | BIOBRANE, per sq cm | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2044 | BIOBRANE Glove, each | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A2045 | NovaShield or NovoGen Wound Matrix, per sq cm | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A8000 | HELMET PROTECTVE SOFT PREFAB COMPONENT ACCSSRIES | Medi-Cal Prior Authorization List, Pg 19 Original policy |
| A8001 | HELMET PROTECTVE HARD PREFAB COMPONENT ACCSSRIES | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| A8002 | HELMET PROTECTIVE SOFT CUSTOM FAB COMP ACCSSRIES | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| A8003 | HELMET PROTECTIVE HARD CUSTOM FAB COMP ACCSSRIES | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| A8004 | SOFT INTERFACE FOR HELMET REPLACEMENT ONLY | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| A9602 | FLUORODOPA F-18, DIAGNOSTIC, PER MILLICURIE | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| A9800 | a radioactive diagnostic agent indicated for positron emission tomography (PET) of prostate-specific | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| A9900 | DME SUP/ACCESS/SRV-COMPON/OTH HCPCS | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| A9999 | MISCELLANEOUS DME SUPPLY OR ACCESSORY NOS | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| B4185 | PARENTERAL NUTR SOL NOS 10 GRMS | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| C1062 | INTRAVERTEBRAL BODY FRACTURE AUGMENTATION WITH IMPLANT (E.G., METAL, POLYMER) | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| C1820 | GEN, NEURO, NON-HF RECHG BAT | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| C1822 | GEN, NEURO, HF, RECHG BAT | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| C1823 | Generator neurostimulator | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| C1824 | GENERATOR CCM IMPLANT | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| C1825 | SINUS BARORECEPTOR STIMULATION LEAD(S) | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| C2596 | PROBE ROBOTIC WATER-JET | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| C2616 | BRACHYTHERAPY NONSTRANDED YTTRIUM-90 PER SOURCE | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| C8001 | 3D anatomical segmentation imaging for preoperative planning, data preparation and transmission, obtained from previous diagnostic computed tomographic or magnetic resonance examination of the same anatomy | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| C9796 | Repair of enterocutaneous fistula small intestine or colon (excluding anorectal fistula) with plug (e.g., porcine small intestine submucosa [SIS]) | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| E0181 | PWR PRESSURE REDUCING MATTRESS OVERLY/PAD PUMP | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| E0182 | PUMP ALTERNATING PRESSURE PAD REPLACEMENT ONLY | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| E0184 | DRY PRESSURE MATTRESS | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| E0193 | POWERED AIR FLOTATION BED | Medi-Cal Prior Authorization List, Pg 20 Original policy |
| E0199 | DRY PRESS PAD MATTRSS STD MATTRSS LENGTH&WIDTH | Medi-Cal Prior Authorization List, Pg 20 Original policy |