Anthem Blue Cross Blue Shield of Georgia policy
CG-MED-99 Intradialytic Parenteral Nutrition
CG-MED-99 Intradialytic Parenteral Nutrition is a public Anthem Blue Cross Blue Shield of Georgia policy (policy CG-MED-99). It lists 19 CPT or HCPCS codes, 18 of them on the Anthem Blue Cross Blue Shield of Georgia prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-MED-99
- Line of business
- Commercial
- 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 Georgia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of Georgia policies |
|---|---|---|---|
| B4164 | On the list | Parenteral nutrition solution; carbohydrates (dextrose), 50% or less (500 ml = 1 unit) - home mix | Policies naming B4164 |
| B4168 | On the list | Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) - home mix | Policies naming B4168 |
| B4172 | Not listed | Policies naming B4172 | |
| B4176 | On the list | Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mix | Policies naming B4176 |
| B4178 | On the list | Parenteral nutrition solution; amino acid, greater than 8.5%, (500 ml = 1 unit) - home mix | Policies naming B4178 |
| B4180 | On the list | Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) - home mix | Policies naming B4180 |
| B4185 | On the list | Parenteral nutrition solution, not otherwise specified, 10 grams lipids | Policies naming B4185 |
| B4187 | On the list | Omegaven, 10 grams lipids | Policies naming B4187 |
| B4189 | On the list | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix | Policies naming B4189 |
| B4193 | On the list | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix | Policies naming B4193 |
| B4197 | On the list | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix | Policies naming B4197 |
| B4199 | On the list | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, over 100 grams of protein - premix | Policies naming B4199 |
| B4216 | On the list | Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) home mix per day | Policies naming B4216 |
| B4220 | On the list | Parenteral nutrition supply kit; premix, per day | Policies naming B4220 |
| B4222 | On the list | Parenteral nutrition supply kit; home mix, per day | Policies naming B4222 |
| B4224 | On the list | Parenteral nutrition administration kit, per day | Policies naming B4224 |
| B5000 | On the list | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - Aminosyn-RF, NephrAmine, RenAmine - premix | Policies naming B5000 |
| B5100 | On the list | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic, HepatAmine - premix | Policies naming B5100 |
| B5200 | On the list | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-branch chain amino acids - FreAmine-HBC - premix | Policies naming B5200 |
All Anthem Blue Cross Blue Shield of Georgia policies · Anthem Blue Cross Blue Shield of Georgia prior authorization CPT list