Anthem Blue Cross Blue Shield of Georgia prior authorization, page 10
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 |
|---|---|---|
| 61796 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 61798 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 62290 | Injection procedure for discography, each level; lumbar | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 62320 | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 62321 | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 62322 | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 62323 | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 62330 | Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance (ie, CT or fluoroscopy), bilateral; one interspace, lumbar | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 62350 | Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 62351 | Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 62360 | Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 62361 | Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 62362 | Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 62380 | Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63001 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63003 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63005 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63012 | Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63015 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63017 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63020 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical(cid:9) | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63030 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63035 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63040 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63042 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63043 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63044 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace | Standard Local Prior Authorization Code List, Pg 25 Original policy |
| 63045 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63046 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63047 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63048 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional vertebral segment, cervical, thoracic, or lumbar | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63050 | Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63051 | Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [eg, wire, suture, mini-plates], when performed) | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63052 | Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63053 | Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional segment | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63055 | Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63056 | Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc) | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63057 | Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63075 | Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63076 | Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63081 | Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63082 | Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63085 | Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63086 | Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63087 | Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment | Standard Local Prior Authorization Code List, Pg 26 Original policy |
| 63088 | Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; each additional segment | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63090 | Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63091 | Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63101 | Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic, single segment | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63102 | Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); lumbar, single segment | Standard Local Prior Authorization Code List, Pg 27 Original policy |