Anthem Blue Cross Blue Shield of Colorado policy
Modifiers 59 and XE, XP, XS, and XU: Distinct Procedural Service - Professional
Modifiers 59 and XE, XP, XS, and XU: Distinct Procedural Service - Professional is a public Anthem Blue Cross Blue Shield of Colorado policy (policy C-09006, effective Mar 15, 2026). It lists 187 CPT or HCPCS codes, 58 of them on the Anthem Blue Cross Blue Shield of Colorado prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- C-09006
- Effective
- Mar 15, 2026
- Line of business
- Commercial
- States
- CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, WI
- 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 |
|---|---|---|---|
| 01996 | Not listed | Policies naming 01996 | |
| 09006 | Not listed | Policies naming 09006 | |
| 15757 | Not listed | Policies naming 15757 | |
| 20527 | Not listed | Policies naming 20527 | |
| 20550 | Not listed | Policies naming 20550 | |
| 20551 | On the list | Injection(S); Tendon Origin/Insertion | Policies naming 20551 |
| 20552 | On the list | Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) | Policies naming 20552 |
| 20553 | On the list | Injection(s); single or multiple trigger point(s), 3 or more muscle(s) | Policies naming 20553 |
| 20560 | On the list | Needle insertion(s) without injection(s); 1 or 2 muscle(s) | Policies naming 20560 |
| 20561 | On the list | Needle insertion(s) without injection(s); 3 or more muscles | Policies naming 20561 |
| 20604 | On the list | Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting | Policies naming 20604 |
| 20606 | On the list | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound gu | Policies naming 20606 |
| 20611 | On the list | Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reportin | Policies naming 20611 |
| 22554 | On the list | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 | Policies naming 22554 |
| 22585 | On the list | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in ad | Policies naming 22585 |
| 22612 | On the list | Arthrodesis, posterior or posterolateral technique, single interspace; lumbar (with lateral transverse technique, when performed) | Policies naming 22612 |
| 22614 | On the list | Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (List separately in addition to code for primary procedure) | Policies naming 22614 |
| 22633 | On the list | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other | Policies naming 22633 |
| 27093 | Not listed | Policies naming 27093 | |
| 27095 | Not listed | Policies naming 27095 | |
| 27275 | On the list | Manipulation, Hip Joint, Requiring General Anesthesia | Policies naming 27275 |
| 29806 | On the list | Arthroscopy, shoulder, surgical; capsulorrhaphy | Policies naming 29806 |
| 29807 | On the list | Arthroscopy, shoulder, surgical; repair of SLAP lesion | Policies naming 29807 |
| 29819 | On the list | Arthroscopy, shoulder, surgical; with removal of loose body or foreign body | Policies naming 29819 |
| 29820 | On the list | Arthroscopy, shoulder, surgical; synovectomy, partial | Policies naming 29820 |
| 29821 | On the list | Arthroscopy, shoulder, surgical; synovectomy, complete | Policies naming 29821 |
| 29822 | On the list | Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, bi | Policies naming 29822 |
| 29823 | On the list | Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilag | Policies naming 29823 |
| 29824 | On the list | Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) | Policies naming 29824 |
| 29825 | On the list | Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation | Policies naming 29825 |
| 29827 | On the list | Arthroscopy, shoulder, surgical; with rotator cuff repair | Policies naming 29827 |
| 29834 | Not listed | Policies naming 29834 | |
| 29835 | Not listed | Policies naming 29835 | |
| 29836 | Not listed | Policies naming 29836 | |
| 29837 | Not listed | Policies naming 29837 | |
| 29838 | Not listed | Policies naming 29838 | |
| 42950 | Not listed | Policies naming 42950 | |
| 43281 | On the list | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of me | Policies naming 43281 |
| 43282 | On the list | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh | Policies naming 43282 |
| 43283 | Not listed | Policies naming 43283 | |
| 43332 | On the list | Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis | Policies naming 43332 |
| 43333 | On the list | Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis | Policies naming 43333 |
| 43644 | Not listed | Policies naming 43644 | |
| 43645 | Not listed | Policies naming 43645 | |
| 43770 | On the list | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric ba | Policies naming 43770 |
| 43771 | Not listed | Policies naming 43771 | |
| 43772 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only | Policies naming 43772 |
| 43773 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device c | Policies naming 43773 |
| 43774 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous | Policies naming 43774 |
| 43775 | Not listed | Policies naming 43775 | |
| 43842 | On the list | Gastric Restrictive Proc, W/O Gastric Bypass, Morbid Obesity; Vertical-Banded Gastroplasty | Policies naming 43842 |
| 43843 | Not listed | Policies naming 43843 | |
| 43845 | Not listed | Policies naming 43845 | |
| 43846 | Not listed | Policies naming 43846 | |
| 43847 | Not listed | Policies naming 43847 | |
| 43848 | Not listed | Policies naming 43848 | |
| 43886 | On the list | Gastric restrictive procedure, open; revision of subcutaneous port component only | Policies naming 43886 |
| 43887 | On the list | Gastric restrictive procedure, open; removal of subcutaneous port component only | Policies naming 43887 |
| 43888 | On the list | Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only | Policies naming 43888 |
| 58140 | Not listed | Policies naming 58140 | |
| 58145 | On the list | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or | Policies naming 58145 |
| 58146 | Not listed | Policies naming 58146 | |
| 58545 | On the list | Laparoscopy, Surg, Myomectomy; 1-4 Intramural Myomas, Total Wt 250 Gms, &/Or Remove Surface Myomas | Policies naming 58545 |
| 58546 | On the list | Laparoscopy, Surg, Myomectomy; 5/> Intramural Myomas &/Or Total Wt >250 Gms | Policies naming 58546 |
| 58561 | On the list | Hysteroscopy, Surgical; W/Removal Leiomyomata | Policies naming 58561 |
| 58570 | Not listed | Policies naming 58570 | |
| 58571 | Not listed | Policies naming 58571 | |
| 58572 | Not listed | Policies naming 58572 | |
| 58573 | Not listed | Policies naming 58573 | |
| 62320 | On the list | Injection(s) of diagnostic or therapeutic substance(s) (eg. anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle | Policies naming 62320 |
| 62321 | On the list | Injection(s) of diagnostic or therapeutic substance(s) (eg. anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle | Policies naming 62321 |
| 62322 | On the list | Injection(s) of diagnostic or therapeutic substances(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution) not including neurolytic substances, including needle | Policies naming 62322 |
| 62323 | On the list | Injection(s) of diagnostic or therapeutic substances(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution) not including neurolytic substances, including needle | Policies naming 62323 |
| 62324 | Not listed | Policies naming 62324 | |
| 62325 | Not listed | Policies naming 62325 | |
| 62326 | Not listed | Policies naming 62326 | |
| 62327 | Not listed | Policies naming 62327 | |
| 63081 | On the list | Vertebral Corpectomy, Anterior; Cervical, 1 Segment | Policies naming 63081 |
| 63090 | On the list | Vertebral Corpectomy, Transperitoneal/Retroperitoneal, Lower Thoracic/Lumbar/Sacral; 1 Segment | Policies naming 63090 |
| 63091 | On the list | Vertebral Corpectomy, Trans/Retroperitoneal, Lower Thoracic/Lumbar/Sacral; Add'l Segment | Policies naming 63091 |
| 63650 | On the list | Percutaneous Implantation, Neurostimulator Electrode Array, Epidural | Policies naming 63650 |
| 63655 | On the list | Laminectomy, Implantation, Neurostimulator Electrodes, Plate/Paddle, Epidural | Policies naming 63655 |
| 64479 | On the list | Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level | Policies naming 64479 |
| 64486 | Not listed | Policies naming 64486 | |
| 64487 | Not listed | Policies naming 64487 | |
| 64488 | Not listed | Policies naming 64488 | |
| 64489 | Not listed | Policies naming 64489 | |
| 76512 | Not listed | Policies naming 76512 | |
| 76604 | Not listed | Policies naming 76604 | |
| 76700 | Not listed | Policies naming 76700 | |
| 76706 | Not listed | Policies naming 76706 | |
| 76770 | Not listed | Policies naming 76770 | |
| 76776 | Not listed | Policies naming 76776 | |
| 76815 | Not listed | Policies naming 76815 | |
| 76857 | Not listed | Policies naming 76857 | |
| 76881 | Not listed | Policies naming 76881 | |
| 76882 | Not listed | Policies naming 76882 | |
| 76942 | Not listed | Policies naming 76942 | |
| 77002 | Not listed | Policies naming 77002 | |
| 77003 | Not listed | Policies naming 77003 | |
| 77012 | Not listed | Policies naming 77012 | |
| 77021 | Not listed | Policies naming 77021 | |
| 77063 | Not listed | Policies naming 77063 | |
| 77065 | Not listed | Policies naming 77065 | |
| 77066 | Not listed | Policies naming 77066 | |
| 77427 | Not listed | Policies naming 77427 | |
| 78265 | Not listed | Policies naming 78265 | |
| 78830 | Not listed | Policies naming 78830 | |
| 78835 | Not listed | Policies naming 78835 | |
| 80305 | Not listed | Policies naming 80305 | |
| 80307 | Not listed | Policies naming 80307 | |
| 80320 | Not listed | Policies naming 80320 | |
| 80377 | Not listed | Policies naming 80377 | |
| 81000 | Not listed | Policies naming 81000 | |
| 81003 | Not listed | Policies naming 81003 | |
| 81005 | Not listed | Policies naming 81005 | |
| 82542 | On the list | Column Chromatography/Mass Spectrometry; Quantitative, Single Stationary & Mobile Phase | Policies naming 82542 |
| 82570 | Not listed | Policies naming 82570 | |
| 83516 | On the list | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitativ | Policies naming 83516 |
| 83520 | On the list | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise sp | Policies naming 83520 |
| 83789 | Not listed | Policies naming 83789 | |
| 83986 | Not listed | Policies naming 83986 | |
| 83992 | Not listed | Policies naming 83992 | |
| 84156 | Not listed | Policies naming 84156 | |
| 84311 | Not listed | Policies naming 84311 | |
| 88141 | Not listed | Policies naming 88141 | |
| 88155 | Not listed | Policies naming 88155 | |
| 88164 | Not listed | Policies naming 88164 | |
| 88167 | Not listed | Policies naming 88167 | |
| 88174 | Not listed | Policies naming 88174 | |
| 88175 | Not listed | Policies naming 88175 | |
| 91065 | Not listed | Policies naming 91065 | |
| 95700 | Not listed | Policies naming 95700 | |
| 95937 | Not listed | Policies naming 95937 | |
| 95940 | Not listed | Policies naming 95940 | |
| 95941 | Not listed | Policies naming 95941 | |
| 95950 | Not listed | Policies naming 95950 | |
| 95953 | Not listed | Policies naming 95953 | |
| 95956 | Not listed | Policies naming 95956 | |
| 95957 | Not listed | Policies naming 95957 | |
| 96365 | On the list | Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour | Policies naming 96365 |
| 96369 | Not listed | Policies naming 96369 | |
| 96372 | On the list | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular | Policies naming 96372 |
| 96373 | Not listed | Policies naming 96373 | |
| 96374 | Not listed | Policies naming 96374 | |
| 96379 | Not listed | Policies naming 96379 | |
| 99201 | Not listed | Policies naming 99201 | |
| 99202 | Not listed | Policies naming 99202 | |
| 99211 | Not listed | Policies naming 99211 | |
| 99215 | Not listed | Policies naming 99215 | |
| 99281 | Not listed | Policies naming 99281 | |
| 99282 | Not listed | Policies naming 99282 | |
| 99283 | Not listed | Policies naming 99283 | |
| 99284 | Not listed | Policies naming 99284 | |
| 99285 | Not listed | Policies naming 99285 | |
| 99381 | Not listed | Policies naming 99381 | |
| 99397 | Not listed | Policies naming 99397 | |
| A4221 | Not listed | Policies naming A4221 | |
| A4222 | Not listed | Policies naming A4222 | |
| E0776 | Not listed | Policies naming E0776 | |
| E0781 | Not listed | Policies naming E0781 | |
| G0101 | Not listed | Policies naming G0101 | |
| G0138 | Not listed | Policies naming G0138 | |
| G0402 | Not listed | Policies naming G0402 | |
| G0438 | Not listed | Policies naming G0438 | |
| G0439 | Not listed | Policies naming G0439 | |
| G0453 | Not listed | Policies naming G0453 | |
| G0480 | Not listed | Policies naming G0480 | |
| G0481 | Not listed | Policies naming G0481 | |
| G0482 | Not listed | Policies naming G0482 | |
| G0483 | Not listed | Policies naming G0483 | |
| G0659 | Not listed | Policies naming G0659 | |
| J1202 | Not listed | Policies naming J1202 | |
| J2001 | Not listed | Policies naming J2001 | |
| L8679 | On the list | Implantable neurostimulator, pulse generator, any type | Policies naming L8679 |
| L8680 | On the list | Implantable neurostimulator electrode, each | Policies naming L8680 |
| L8687 | On the list | Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension | Policies naming L8687 |
| Q0091 | Not listed | Policies naming Q0091 | |
| Q3014 | Not listed | Policies naming Q3014 | |
| S0610 | Not listed | Policies naming S0610 | |
| S0612 | Not listed | Policies naming S0612 | |
| S5492 | Not listed | Policies naming S5492 | |
| S5497 | Not listed | Policies naming S5497 | |
| S9339 | Not listed | Policies naming S9339 | |
| S9349 | Not listed | Policies naming S9349 | |
| S9355 | Not listed | Policies naming S9355 | |
| S9810 | Not listed | Policies naming S9810 |
All Anthem Blue Cross Blue Shield of Colorado policies · Anthem Blue Cross Blue Shield of Colorado prior authorization CPT list