Anthem Blue Cross Blue Shield of Colorado policy
ASC Grouper Listing
ASC Grouper Listing is a public Anthem Blue Cross Blue Shield of Colorado policy. It lists 3,389 CPT or HCPCS codes, 1164 of them on the Anthem Blue Cross Blue Shield of Colorado prior authorization list. Not a coverage decision; the payer's own document governs.
View the original policy (PDF) ↗
- Line of business
- Commercial
- States
- CO
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of Colorado prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of Colorado policies |
|---|---|---|---|
| 0191T | On the list | Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular meshwork | Policies naming 0191T |
| 0249T | Not listed | Policies naming 0249T | |
| 0253T | On the list | Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space | Policies naming 0253T |
| 0387T | Not listed | Policies naming 0387T | |
| 0396T | Not listed | Policies naming 0396T | |
| 0397T | Not listed | Policies naming 0397T | |
| 0398T | Not listed | Policies naming 0398T | |
| 0402T | On the list | Collagen cross-linking of cornea, including removal of the corneal epithelium, when performed, and intraoperative pachymetry, when performed | Policies naming 0402T |
| 0406T | Not listed | Policies naming 0406T | |
| 0407T | Not listed | Policies naming 0407T | |
| 0408T | On the list | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Policies naming 0408T |
| 0409T | On the list | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Policies naming 0409T |
| 0410T | On the list | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Policies naming 0410T |
| 0411T | On the list | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Policies naming 0411T |
| 0412T | On the list | Removal of permanent cardiac contractility modulation system; pulse generator only | Policies naming 0412T |
| 0413T | On the list | Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular) | Policies naming 0413T |
| 0414T | On the list | Removal and replacement of permanent cardiac contractility modulation system pulse generator only | Policies naming 0414T |
| 0415T | On the list | Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead) | Policies naming 0415T |
| 0416T | On the list | Relocation of skin pocket for implanted cardiac contractility modulation pulse generator | Policies naming 0416T |
| 0419T | Not listed | Policies naming 0419T | |
| 0420T | Not listed | Policies naming 0420T | |
| 0421T | Not listed | Policies naming 0421T | |
| 0424T | Not listed | Policies naming 0424T | |
| 0425T | Not listed | Policies naming 0425T | |
| 0426T | Not listed | Policies naming 0426T | |
| 0427T | Not listed | Policies naming 0427T | |
| 0428T | Not listed | Policies naming 0428T | |
| 0429T | Not listed | Policies naming 0429T | |
| 0430T | Not listed | Policies naming 0430T | |
| 0431T | Not listed | Policies naming 0431T | |
| 0432T | Not listed | Policies naming 0432T | |
| 0433T | Not listed | Policies naming 0433T | |
| 0437T | Not listed | Policies naming 0437T | |
| 0438T | Not listed | Policies naming 0438T | |
| 0440T | On the list | Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve | Policies naming 0440T |
| 0441T | On the list | Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve | Policies naming 0441T |
| 0442T | On the list | Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve) | Policies naming 0442T |
| 0444T | Not listed | Policies naming 0444T | |
| 0445T | Not listed | Policies naming 0445T | |
| 0446T | Not listed | Policies naming 0446T | |
| 0447T | Not listed | Policies naming 0447T | |
| 0448T | Not listed | Policies naming 0448T | |
| 0449T | On the list | Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device | Policies naming 0449T |
| 0450T | On the list | Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; each additional device (List separately in addition to | Policies naming 0450T |
| 0451T | Not listed | Policies naming 0451T | |
| 0452T | Not listed | Policies naming 0452T | |
| 0453T | Not listed | Policies naming 0453T | |
| 0454T | Not listed | Policies naming 0454T | |
| 0455T | Not listed | Policies naming 0455T | |
| 0456T | Not listed | Policies naming 0456T | |
| 0457T | Not listed | Policies naming 0457T | |
| 0458T | Not listed | Policies naming 0458T | |
| 0459T | Not listed | Policies naming 0459T | |
| 0460T | Not listed | Policies naming 0460T | |
| 0461T | Not listed | Policies naming 0461T | |
| 0465T | Not listed | Policies naming 0465T | |
| 0466T | Not listed | Policies naming 0466T | |
| 0467T | Not listed | Policies naming 0467T | |
| 0468T | Not listed | Policies naming 0468T | |
| 0474T | On the list | Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space | Policies naming 0474T |
| 0479T | Not listed | Policies naming 0479T | |
| 0480T | Not listed | Policies naming 0480T | |
| 0481T | On the list | Injection(s), autologous white blood cell concentrate (autologous protein solution), any site, including image guidance, harvesting and preparation, when performed | Policies naming 0481T |
| 0483T | On the list | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed | Policies naming 0483T |
| 0484T | On the list | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (eg, thoracotomy, transapical) | Policies naming 0484T |
| 0489T | On the list | Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation | Policies naming 0489T |
| 0490T | On the list | Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands | Policies naming 0490T |
| 0491T | Not listed | Policies naming 0491T | |
| 0492T | Not listed | Policies naming 0492T | |
| 0494T | On the list | Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system, including decannulation, separation from the perfusion sys | Policies naming 0494T |
| 0499T | Not listed | Policies naming 0499T | |
| 10035 | Not listed | Policies naming 10035 | |
| 10036 | Not listed | Policies naming 10036 | |
| 10061 | On the list | Incision & Drainage, Abscess; Complicated/Multiple | Policies naming 10061 |
| 10081 | On the list | Incision & Drainage, Pilonidal Cyst; Complicated | Policies naming 10081 |
| 10121 | On the list | Incision & Removal, Fb, Subq Tissues; Complicated | Policies naming 10121 |
| 10140 | On the list | Incision & Drainage, Hematoma, Seroma/Fluid Collection | Policies naming 10140 |
| 10180 | On the list | Incision & Drainage, Complex, Postoperative Wound Infection | Policies naming 10180 |
| 11010 | On the list | Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues | Policies naming 11010 |
| 11011 | Not listed | Policies naming 11011 | |
| 11012 | On the list | Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fa | Policies naming 11012 |
| 11042 | On the list | Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less | Policies naming 11042 |
| 11043 | Not listed | Policies naming 11043 | |
| 11044 | On the list | Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less | Policies naming 11044 |
| 11045 | Not listed | Policies naming 11045 | |
| 11046 | Not listed | Policies naming 11046 | |
| 11047 | Not listed | Policies naming 11047 | |
| 11100 | Not listed | Policies naming 11100 | |
| 11101 | Not listed | Policies naming 11101 | |
| 11402 | On the list | Excise, Benign Skin Lesion, Incl Margins, Except Skin Tag, Trunk/Arms/Legs; Excised Diam 1.1-2.0 Cm | Policies naming 11402 |
| 11403 | On the list | Excise, Benign Skin Lesion, Incl Margins, Except Skin Tag, Trunk/Arms/Legs; Excised Diam 2.1-3.0 Cm | Policies naming 11403 |
| 11404 | On the list | Excise, Benign Skin Lesion, Incl Margins, Except Skin Tag, Trunk/Arms/Legs; Excised Diam 3.1-4.0 Cm | Policies naming 11404 |
| 11406 | On the list | Excise, Benign Skin Lesion, Incl Margins, Except Skin Tag, Trunk/Arms/Legs; Excised Diam > 4.0 Cm | Policies naming 11406 |
| 11421 | On the list | Excise Ben Skin Lesion W/Marg, Except Skin Tag Scalp/Neck/Hands/Feet/Genital; Excise Diam 0.6-1.0cm | Policies naming 11421 |
| 11422 | On the list | Excise Ben Skin Lesion W/Marg, Except Skin Tag Scalp/Neck/Hands/Feet/Genital; Excise Diam 1.1-2.0cm | Policies naming 11422 |
| 11423 | On the list | Excise Ben Skin Lesion W/Marg, Except Skin Tag Scalp/Neck/Hands/Feet/Genital; Excise Diam 2.1-3.0cm | Policies naming 11423 |
| 11424 | On the list | Excise Ben Skin Lesion W/Marg, Except Skin Tag Scalp/Neck/Hands/Feet/Genital; Excise Diam 3.1-4.0cm | Policies naming 11424 |
| 11426 | On the list | Excise Benign Skin Lesion W/Marg, Except Skin Tag Scalp/Neck/Hands/Ft/Genital; Excise Diam >4.0cm | Policies naming 11426 |
| 11441 | On the list | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, l | Policies naming 11441 |
| 11442 | On the list | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, l | Policies naming 11442 |
| 11443 | On the list | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, l | Policies naming 11443 |
| 11444 | On the list | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, l | Policies naming 11444 |
| 11446 | On the list | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, l | Policies naming 11446 |
| 11450 | On the list | Excision, Skin & Subq Tissue, Hidradenitis, Axillary; Simple/Intermediate Repair | Policies naming 11450 |
| 11451 | On the list | Excision, Skin & Subq Tissue, Hidradenitis, Axillary; W/Complex Repair | Policies naming 11451 |
| 11462 | On the list | Excision, Skin & Subq Tissue, Hidradenitis, Inguinal; Simple/Intermediate Repair | Policies naming 11462 |
| 11463 | On the list | Excision, Skin & Subq Tissue, Hidradenitis, Inguinal; W/Complex Repair | Policies naming 11463 |
| 11470 | On the list | Excision, Skin & Subq Tissue, Hidradenitis, Perianal/Perineal/Umbilical; Simple/Intermediate Repair | Policies naming 11470 |
| 11471 | On the list | Excision, Skin & Subq Tissue, Hidradenitis, Perianal/Perineal/Umbilical; W/ Complex Repair | Policies naming 11471 |
| 11602 | On the list | Excision, Malignant Lesion, Incl Margins, Trunk/Arms/Legs; Excised Diam 1.1 To 2.0 Cm | Policies naming 11602 |
| 11603 | On the list | Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm | Policies naming 11603 |
| 11604 | On the list | Excision, Malignant Lesion, Incl Margins, Trunk/Arms/Legs; Excised Diam 3.1 To 4.0 Cm | Policies naming 11604 |
| 11606 | On the list | Excision, Malignant Lesion, Incl Margins, Trunk/Arms/Legs; Excised Diam > 4.0 Cm | Policies naming 11606 |
| 11622 | On the list | Excision, Malignant Lesion, Incl Margins, Scalp/Neck/Hands/Feet/Genitalia; Excised Diam 1.1-2.0 Cm | Policies naming 11622 |
| 11623 | On the list | Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm | Policies naming 11623 |
| 11624 | On the list | Excision, Malignant Lesion, Incl Margins, Scalp/Neck/Hands/Feet/Genitalia; Excised Diam 3.1-4.0 Cm | Policies naming 11624 |
| 11626 | On the list | Excision, Malignant Lesion, Incl Margins, Scalp/Neck/Hands/Feet/Genitalia; Excised Diam > 4.0 Cm | Policies naming 11626 |
| 11640 | On the list | Excision, Malignant Lesion, Incl Margins, Face/Ears/Eyelids/Nose/Lips/Muco; Excised Diam 0.5 Cm/< | Policies naming 11640 |
| 11642 | On the list | Excision, Malignant Lesion, Incl Margins, Face/Ears/Eyelids/Nose/Lips/Muco; Excised Diam 1.1-2.0 Cm | Policies naming 11642 |
| 11643 | On the list | Excision, Malignant Lesion, Incl Margins, Face/Ears/Eyelids/Nose/Lips/Muco; Excised Diam 2.1-3.0 Cm | Policies naming 11643 |
| 11644 | On the list | Excision, Malignant Lesion, Incl Margins, Face/Ears/Eyelids/Nose/Lips/Muco; Excised Diam 3.1-4.0 Cm | Policies naming 11644 |
| 11646 | On the list | Excision, Malignant Lesion, Incl Margins, Face/Ears/Eyelids/Nose/Lips/Muco; Excised Diam > 4.0 Cm | Policies naming 11646 |
| 11770 | On the list | Excision, Pilonidal Cyst/Sinus; Simple | Policies naming 11770 |
| 11771 | Not listed | Policies naming 11771 | |
| 11772 | On the list | Excision, Pilonidal Cyst/Sinus; Complicated | Policies naming 11772 |
| 11960 | Not listed | Policies naming 11960 | |
| 11970 | Not listed | Policies naming 11970 | |
| 11971 | Not listed | Policies naming 11971 | |
| 12004 | Not listed | Policies naming 12004 | |
| 12005 | Not listed | Policies naming 12005 | |
| 12006 | Not listed | Policies naming 12006 | |
| 12007 | Not listed | Policies naming 12007 | |
| 12014 | Not listed | Policies naming 12014 | |
| 12015 | Not listed | Policies naming 12015 | |
| 12016 | Not listed | Policies naming 12016 | |
| 12017 | Not listed | Policies naming 12017 | |
| 12018 | Not listed | Policies naming 12018 | |
| 12020 | On the list | Treatment, Superficial Wound Dehiscence; Simple Closure | Policies naming 12020 |
| 12021 | Not listed | Policies naming 12021 | |
| 12032 | On the list | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm | Policies naming 12032 |
| 12034 | On the list | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm | Policies naming 12034 |
| 12035 | On the list | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm | Policies naming 12035 |
| 12036 | Not listed | Policies naming 12036 | |
| 12037 | On the list | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm | Policies naming 12037 |
| 12042 | On the list | Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm | Policies naming 12042 |
| 12044 | Not listed | Policies naming 12044 | |
| 12045 | Not listed | Policies naming 12045 | |
| 12046 | Not listed | Policies naming 12046 | |
| 12047 | Not listed | Policies naming 12047 | |
| 12052 | On the list | Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm | Policies naming 12052 |
| 12053 | Not listed | Policies naming 12053 | |
| 12054 | Not listed | Policies naming 12054 | |
| 12055 | Not listed | Policies naming 12055 | |
| 12056 | Not listed | Policies naming 12056 | |
| 12057 | Not listed | Policies naming 12057 | |
| 13100 | On the list | Repair, Complex, Trunk; 1.1 To 2.5 Cm | Policies naming 13100 |
| 13101 | On the list | Repair, Complex, Trunk; 2.6 To 7.5 Cm | Policies naming 13101 |
| 13102 | Not listed | Policies naming 13102 | |
| 13120 | On the list | Repair, Complex, Scalp, Arms, &/Or Legs; 1.1 To 2.5 Cm | Policies naming 13120 |
| 13121 | On the list | Repair, Complex, Scalp, Arms, &/Or Legs; 2.6 To 7.5 Cm | Policies naming 13121 |
| 13122 | Not listed | Policies naming 13122 | |
| 13131 | On the list | Repair, Complex, Forehead/Cheeks/Chin/Mouth/Neck/Axillae/Genitalia/Hands/Feet; 1.1-2.5 Cm | Policies naming 13131 |
| 13132 | On the list | Repair, Complex, Forehead/Cheeks/Chin/Mouth/Neck/Axillae/Genitalia/Hands/Feet; 2.6-7.5 Cm | Policies naming 13132 |
| 13133 | Not listed | Policies naming 13133 | |
| 13151 | On the list | Repair, Complex, Eyelids, Nose, Ears &/Or Lips; 1.1 To 2.5 Cm | Policies naming 13151 |
| 13152 | On the list | Repair, Complex, Eyelids, Nose, Ears &/Or Lips; 2.6 To 7.5 Cm | Policies naming 13152 |
| 13153 | Not listed | Policies naming 13153 | |
| 13160 | On the list | Secondary Closure, Surgical Wound/Dehiscence, Extensive/Complicated | Policies naming 13160 |
| 14000 | Not listed | Policies naming 14000 | |
| 14001 | Not listed | Policies naming 14001 | |
| 14020 | On the list | Adjacent Tissue Transfer/Rearrangement, Scalp, Arms &/Or Legs; Defect 10 Sq Cm/< | Policies naming 14020 |
| 14021 | Not listed | Policies naming 14021 | |
| 14040 | On the list | Adjacent Tissue Transfer, Forehead/Cheeks/Chin/Mouth/Neck/Axillae/Genitalia/Hands/Feet; 10 Sq Cm/< | Policies naming 14040 |
| 14041 | On the list | Adjacent Tissue Transfer, Forehead/Cheeks/Chin/Mouth/Neck/Axillae/Genitalia/Hands/Feet;10.1-30.0sqcm | Policies naming 14041 |
| 14060 | On the list | Adjacent Tissue Transfer/Rearrangement, Eyelids/Nose/Ears/Lips; Defect 10 Sq Cm/< | Policies naming 14060 |
| 14061 | On the list | Adjacent Tissue Transfer/Rearrangement, Eyelids/Nose/Ears/Lips; Defect 10.1- 30.0 Sq Cm | Policies naming 14061 |
| 14301 | On the list | Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm | Policies naming 14301 |
| 14302 | Not listed | Policies naming 14302 | |
| 14350 | Not listed | Policies naming 14350 | |
| 15002 | Not listed | Policies naming 15002 | |
| 15003 | Not listed | Policies naming 15003 | |
| 15004 | On the list | Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutane | Policies naming 15004 |
| 15005 | Not listed | Policies naming 15005 | |
| 15040 | Not listed | Policies naming 15040 | |
| 15050 | Not listed | Policies naming 15050 | |
| 15100 | On the list | Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and childr | Policies naming 15100 |
| 15101 | Not listed | Policies naming 15101 | |
| 15110 | Not listed | Policies naming 15110 | |
| 15111 | Not listed | Policies naming 15111 | |
| 15115 | Not listed | Policies naming 15115 | |
| 15116 | Not listed | Policies naming 15116 | |
| 15120 | On the list | Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digi | Policies naming 15120 |
| 15121 | Not listed | Policies naming 15121 | |
| 15130 | Not listed | Policies naming 15130 | |
| 15131 | Not listed | Policies naming 15131 | |
| 15135 | Not listed | Policies naming 15135 | |
| 15136 | Not listed | Policies naming 15136 | |
| 15150 | On the list | Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less | Policies naming 15150 |
| 15151 | On the list | Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) | Policies naming 15151 |
| 15152 | Not listed | Policies naming 15152 | |
| 15155 | On the list | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less | Policies naming 15155 |
| 15156 | Not listed | Policies naming 15156 | |
| 15157 | Not listed | Policies naming 15157 | |
| 15200 | Not listed | Policies naming 15200 | |
| 15201 | Not listed | Policies naming 15201 | |
| 15220 | On the list | Full Thickness Graft, Free, W/Closure Donor Site, Scalp/Arms/Legs; 20 Sq Cm/< | Policies naming 15220 |
| 15221 | Not listed | Policies naming 15221 | |
| 15240 | On the list | Full Thickness Graft, Free, W/Closure Donor, Face/Neck/Axillae/Genitalia/Hands/Feet; 20 Sq Cm/< | Policies naming 15240 |
| 15241 | Not listed | Policies naming 15241 | |
| 15260 | On the list | Full Thickness Graft, Free, W/Closure Donor Site, Nose/Ears/Eyelids/Lips; 20 Sq Cm/< | Policies naming 15260 |
| 15261 | Not listed | Policies naming 15261 | |
| 15271 | On the list | Application Of Skin Substitute Graft To Trunk, Arms, Legs, Total Wound Surface Area Up To 100 Sq Cm; First 25 Sq Cm Or Less Wound Surface Area | Policies naming 15271 |
| 15272 | Not listed | Policies naming 15272 | |
| 15273 | On the list | Application Of Skin Substitute Graft To Trunk, Arms, Legs, Total Wound Surface Area Greater Than Or Equal To 100 Sq Cm; First 100 Sq Cm Wound Surface Area, Or 1% Of Body Area | Policies naming 15273 |
| 15274 | Not listed | Policies naming 15274 | |
| 15275 | On the list | Application Of Skin Substitute Graft To Face, Scalp, Eyelids, Mouth, Neck, Ears, Orbits, Genitalia, Hands, Feet, And/Or Multiple Digits, Total Wound Surface Area Up To 100 Sq | Policies naming 15275 |
| 15276 | Not listed | Policies naming 15276 | |
| 15277 | On the list | Application Of Skin Substitute Graft To Face, Scalp, Eyelids, Mouth, Neck, Ears, Orbits, Genitalia, Hands, Feet, And/Or Multiple Digits, Total Wound Surface Area Greater Than | Policies naming 15277 |
| 15278 | Not listed | Policies naming 15278 | |
| 15570 | Not listed | Policies naming 15570 | |
| 15572 | Not listed | Policies naming 15572 | |
| 15574 | Not listed | Policies naming 15574 | |
| 15576 | On the list | Formation, Direct/Tubed Pedicle, W/Wo Transfer; Eyelids/Nose/Ears/Lips/Intraoral | Policies naming 15576 |
| 15600 | Not listed | Policies naming 15600 | |
| 15610 | Not listed | Policies naming 15610 | |
| 15620 | Not listed | Policies naming 15620 | |
| 15630 | Not listed | Policies naming 15630 | |
| 15650 | Not listed | Policies naming 15650 | |
| 15730 | Not listed | Policies naming 15730 | |
| 15731 | Not listed | Policies naming 15731 | |
| 15732 | Not listed | Policies naming 15732 | |
| 15733 | Not listed | Policies naming 15733 | |
| 15734 | Not listed | Policies naming 15734 | |
| 15736 | Not listed | Policies naming 15736 | |
| 15738 | Not listed | Policies naming 15738 | |
| 15740 | Not listed | Policies naming 15740 | |
| 15750 | Not listed | Policies naming 15750 | |
| 15760 | On the list | Graft; Composite, W/Primary Closure, Donor Area | Policies naming 15760 |
| 15770 | On the list | Graft; Derma-Fat-Fascia | Policies naming 15770 |
| 15775 | On the list | Punch Graft, Hair Transplant; 1-15 Punch Grafts | Policies naming 15775 |
| 15776 | On the list | Punch Graft, Hair Transplant; > 15 Punch Grafts | Policies naming 15776 |
| 15777 | Not listed | Policies naming 15777 | |
| 15820 | On the list | Blepharoplasty, Lower Eyelid | Policies naming 15820 |
| 15821 | On the list | Blepharoplasty, Lower Eyelid; W/Extensive Herniated Fat Pad | Policies naming 15821 |
| 15822 | On the list | Blepharoplasty, Upper Eyelid | Policies naming 15822 |
| 15823 | On the list | Blepharoplasty, Upper Eyelid; W/Excessive Skin Weighting Down Lid | Policies naming 15823 |
| 15824 | On the list | Rhytidectomy; Forehead | Policies naming 15824 |
| 15825 | On the list | Rhytidectomy; Neck W/Platysmal Tightening (Platysmal Flap, P-Flap) | Policies naming 15825 |
| 15826 | On the list | Rhytidectomy; Glabellar Frown Lines | Policies naming 15826 |
| 15828 | On the list | Rhytidectomy; Cheek, Chin, & Neck | Policies naming 15828 |
| 15829 | On the list | Rhytidectomy; Superficial Musculoaponeurotic System (Smas) Flap | Policies naming 15829 |
| 15830 | On the list | Excision, excessive skin and subcutaneous tissue (incluedes lipectomy, abdomen, infraumbilical panniculectomy | Policies naming 15830 |
| 15832 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh | Policies naming 15832 |
| 15833 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg | Policies naming 15833 |
| 15834 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip | Policies naming 15834 |
| 15835 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock | Policies naming 15835 |
| 15836 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm | Policies naming 15836 |
| 15839 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area | Policies naming 15839 |
| 15840 | On the list | Graft, Facial Nerve Paralysis; Free Fascia Graft (W/Obtaining Fascia) | Policies naming 15840 |
| 15841 | On the list | Graft, Facial Nerve Paralysis; Free Muscle Graft (W/Obtaining Graft) | Policies naming 15841 |
| 15842 | On the list | Graft, Facial Nerve Paralysis; Free Muscle Flap, Microsurgical Technique | Policies naming 15842 |
| 15845 | On the list | Graft, Facial Nerve Paralysis; Regional Muscle Transfer | Policies naming 15845 |
| 15847 | Not listed | Policies naming 15847 | |
| 15850 | Not listed | Policies naming 15850 | |
| 15851 | Not listed | Policies naming 15851 | |
| 15876 | On the list | Suction Assisted Lipectomy; Head & Neck | Policies naming 15876 |
| 15877 | On the list | Suction Assisted Lipectomy; Trunk | Policies naming 15877 |
| 15878 | On the list | Suction Assisted Lipectomy; Upper Extremity | Policies naming 15878 |
| 15879 | On the list | Suction Assisted Lipectomy; Lower Extremity | Policies naming 15879 |
| 15920 | Not listed | Policies naming 15920 | |
| 15922 | Not listed | Policies naming 15922 | |
| 15931 | Not listed | Policies naming 15931 | |
| 15933 | Not listed | Policies naming 15933 | |
| 15934 | Not listed | Policies naming 15934 | |
| 15935 | Not listed | Policies naming 15935 | |
| 15936 | Not listed | Policies naming 15936 | |
| 15937 | Not listed | Policies naming 15937 | |
| 15940 | Not listed | Policies naming 15940 | |
| 15941 | Not listed | Policies naming 15941 | |
| 15944 | Not listed | Policies naming 15944 | |
| 15945 | Not listed | Policies naming 15945 | |
| 15946 | Not listed | Policies naming 15946 | |
| 15950 | Not listed | Policies naming 15950 | |
| 15951 | Not listed | Policies naming 15951 | |
| 15952 | Not listed | Policies naming 15952 | |
| 15953 | Not listed | Policies naming 15953 | |
| 15956 | Not listed | Policies naming 15956 | |
| 15958 | Not listed | Policies naming 15958 | |
| 16025 | Not listed | Policies naming 16025 | |
| 16030 | Not listed | Policies naming 16030 | |
| 19020 | Not listed | Policies naming 19020 | |
| 19081 | Not listed | Policies naming 19081 | |
| 19082 | Not listed | Policies naming 19082 | |
| 19083 | Not listed | Policies naming 19083 | |
| 19084 | Not listed | Policies naming 19084 | |
| 19085 | Not listed | Policies naming 19085 | |
| 19086 | Not listed | Policies naming 19086 | |
| 19100 | Not listed | Policies naming 19100 | |
| 19101 | Not listed | Policies naming 19101 | |
| 19110 | Not listed | Policies naming 19110 |
And 3,089 more in the original policy.
All Anthem Blue Cross Blue Shield of Colorado policies · Anthem Blue Cross Blue Shield of Colorado prior authorization CPT list