Anthem Blue Cross Blue Shield of Georgia prior authorization, page 11
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 |
|---|---|---|
| 63103 | 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 or lumbar, each additional segment | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63185 | Laminectomy with rhizotomy; 1 or 2 segments | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63190 | Laminectomy with rhizotomy; more than 2 segments | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63200 | Laminectomy, with release of tethered spinal cord, lumbar | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63252 | Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63265 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63267 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63270 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63272 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63275 | Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63277 | Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63280 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63282 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63285 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63287 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63290 | Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63300 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63307 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach | Standard Local Prior Authorization Code List, Pg 27 Original policy |
| 63308 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; each additional segment (List separately in addition to codes for single segment) | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 63620 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 63650 | Percutaneous implantation of neurostimulator electrode array, epidural | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 63655 | Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 63663 | Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 63664 | Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 63685 | Insertion or replacement of spinal neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 63688 | Revision or removal of implanted spinal neurostimulator pulse generator or receiver, with detachable connection to electrode array | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 64479 | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging, Guidance (fluoroscopy or CT); cervical or thoracic, single level | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 64480 | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging, Guidance (fluoroscopy or CT); cervical or thoracic, each additional level | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 64483 | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging, Guidance (fluoroscopy or CT); lumbar or sacral, single level | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 64484 | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging, Guidance (fluoroscopy or CT); lumbar or sacral, each additional level | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 64490 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 64491 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 64492 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 64493 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 64494 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 64495 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) | Standard Local Prior Authorization Code List, Pg 28 Original policy |
| 64561 | Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64566 | Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64567 | Percutaneous electrical nerve field stimulation, cranial nerves, without implantation | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64581 | Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64582 | Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64585 | Revision or removal of peripheral neurostimulator electrode array | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64600 | Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64605 | Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64610 | Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64625 | Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64629 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64633 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64634 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64635 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint | Standard Local Prior Authorization Code List, Pg 29 Original policy |