Anthem Blue Cross Blue Shield of Georgia policy
Modifiers 50 and 51: Multiple and Bilateral Surgery - Professional
Modifiers 50 and 51: Multiple and Bilateral Surgery - Professional is a public Anthem Blue Cross Blue Shield of Georgia policy (policy C-08004, effective Oct 30, 2023). It lists 63 CPT or HCPCS codes, 25 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
- C-08004
- Effective
- Oct 30, 2023
- 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 Georgia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of Georgia policies |
|---|---|---|---|
| 08004 | Not listed | Policies naming 08004 | |
| 29806 | On the list | Arthroscopy, shoulder, surgical; capsulorrhaphy | Policies naming 29806 |
| 29825 | On the list | Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation | Policies naming 29825 |
| 29826 | On the list | Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed | Policies naming 29826 |
| 29827 | On the list | Arthroscopy, shoulder, surgical; with rotator cuff repair | Policies naming 29827 |
| 29828 | On the list | Arthroscopy, shoulder, surgical; biceps tenodesis | Policies naming 29828 |
| 29830 | Not listed | Policies naming 29830 | |
| 29834 | Not listed | Policies naming 29834 | |
| 29838 | Not listed | Policies naming 29838 | |
| 29840 | Not listed | Policies naming 29840 | |
| 29843 | Not listed | Policies naming 29843 | |
| 29847 | Not listed | Policies naming 29847 | |
| 29860 | On the list | Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) | Policies naming 29860 |
| 29861 | On the list | Arthroscopy, hip, surgical; with removal of loose body or foreign body | Policies naming 29861 |
| 29863 | On the list | Arthroscopy, hip, surgical; with synovectomy | Policies naming 29863 |
| 29870 | On the list | Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) | Policies naming 29870 |
| 29871 | On the list | Arthroscopy, knee, surgical; for infection, lavage and drainage | Policies naming 29871 |
| 29887 | On the list | Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation | Policies naming 29887 |
| 29914 | On the list | Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) | Policies naming 29914 |
| 29916 | On the list | Arthroscopy, hip, surgical; with labral repair | Policies naming 29916 |
| 31622 | Not listed | Policies naming 31622 | |
| 31623 | Not listed | Policies naming 31623 | |
| 31625 | Not listed | Policies naming 31625 | |
| 31626 | Not listed | Policies naming 31626 | |
| 31627 | Not listed | Policies naming 31627 | |
| 31628 | Not listed | Policies naming 31628 | |
| 31631 | Not listed | Policies naming 31631 | |
| 31634 | Not listed | Policies naming 31634 | |
| 31636 | Not listed | Policies naming 31636 | |
| 31638 | Not listed | Policies naming 31638 | |
| 31640 | Not listed | Policies naming 31640 | |
| 31641 | Not listed | Policies naming 31641 | |
| 31645 | Not listed | Policies naming 31645 | |
| 31647 | Not listed | Policies naming 31647 | |
| 31648 | Not listed | Policies naming 31648 | |
| 31660 | On the list | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe | Policies naming 31660 |
| 31661 | On the list | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes | Policies naming 31661 |
| 36415 | Not listed | Policies naming 36415 | |
| 36416 | Not listed | Policies naming 36416 | |
| 43210 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed | Policies naming 43210 |
| 43233 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) | Policies naming 43233 |
| 43235 | On the list | Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | Policies naming 43235 |
| 43236 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance | Policies naming 43236 |
| 43259 | Not listed | Policies naming 43259 | |
| 43260 | Not listed | Policies naming 43260 | |
| 43261 | Not listed | Policies naming 43261 | |
| 43265 | Not listed | Policies naming 43265 | |
| 43266 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) | Policies naming 43266 |
| 43270 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) | Policies naming 43270 |
| 43274 | Not listed | Policies naming 43274 | |
| 43278 | Not listed | Policies naming 43278 | |
| 43290 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon | Policies naming 43290 |
| 43291 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s) | Policies naming 43291 |
| 43497 | On the list | Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM]) | Policies naming 43497 |
| 45378 | Not listed | Policies naming 45378 | |
| 45379 | Not listed | Policies naming 45379 | |
| 45393 | Not listed | Policies naming 45393 | |
| 45395 | Not listed | Policies naming 45395 | |
| 45397 | Not listed | Policies naming 45397 | |
| 45398 | Not listed | Policies naming 45398 | |
| G0289 | On the list | Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee | Policies naming G0289 |
| G6024 | Not listed | Policies naming G6024 | |
| G6025 | Not listed | Policies naming G6025 |
All Anthem Blue Cross Blue Shield of Georgia policies · Anthem Blue Cross Blue Shield of Georgia prior authorization CPT list