Anthem Blue Cross Blue Shield of Georgia prior authorization
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 |
|---|---|---|
| 00170 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 01941 | Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; cervical or thoracic | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 01942 | Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; lumbar or sacral | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 11755 | Bx, Nail Unit (Sep Proc) | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 15011 | Harvest of skin for autograft; first | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 15013 | Preparation of skin autograft, requiring enzymatic processing,; first 25 sq cm or less | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 15015 | Application of skin autograft; first 480 sq cm or less | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 15017 | Application of skin autograft; first 480 sq cm or less | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 15151 | Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 17311 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, colo | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 17313 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, colo | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 19105 | Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 19296 | Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 20555 | Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure) | Standard Local Prior Authorization Code List, Pg 1 Original policy |
| 20560 | Needle insertion(s) without injection(s); 1 or 2 muscle(s) | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20561 | Needle insertion(s) without injection(s); 3 or more muscles | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20605 | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20606 | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20930 | Allograft, morselized, or placement of osteopromotive material, for spine surgery only | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20931 | Allograft, structural, for spine surgery only | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20932 | Allograft, includes templating, cutting, placement and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20933 | Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (ie, hemicylindrical) | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20934 | Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (ie, cylindrical) | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20936 | Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20937 | Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20938 | Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20939 | Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20974 | Electrical stimulation to aid bone healing; noninvasive (nonoperative) | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20982 | Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 20983 | Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 21010 | Arthrotomy, temporomandibular joint | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 21050 | Condylectomy, temporomandibular joint (separate procedure) | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 21060 | Meniscectomy, partial or complete, temporomandibular joint (separate procedure) | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 21073 | Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care) | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 21110 | Application of interdental fixation device for conditions other than fracture or dislocation, includes removal | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 21116 | Injection procedure for temporomandibular joint arthrography | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 21240 | Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 21242 | Arthroplasty, temporomandibular joint, with allograft | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 21243 | Arthroplasty, temporomandibular joint, with prosthetic joint replacement | Standard Local Prior Authorization Code List, Pg 2 Original policy |
| 21811 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 21812 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22206 | Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22207 | Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); lumbar | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22208 | Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22210 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22212 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22214 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22216 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22220 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22222 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic | Standard Local Prior Authorization Code List, Pg 3 Original policy |