Anthem Blue Cross Blue Shield of Georgia prior authorization, page 12
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 |
|---|---|---|
| 64636 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64654 | Initial open implantation of baroreflex activation therapy (BAT) modulation system, including lead placement onto the carotid sinus, lead tunnelling, connection to a pulse generator placed in a distant subcutaneous pocket (ie, total system), and intraoperative interrogation and programming | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64655 | Revision or replacement of baroreflex activation therapy (BAT) modulation system, with intraoperative interrogation and programming; lead only | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64656 | Revision or replacement of baroreflex activation therapy (BAT) modulation system, with intraoperative interrogation and programming; pulse generator only | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64657 | Removal of baroreflex activation therapy (BAT) modulation system; total system, including lead and pulse generator | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64658 | Removal of baroreflex activation therapy (BAT) modulation system; lead only | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 64659 | Removal of baroreflex activation therapy (BAT) modulation system; pulse generator only | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 65756 | Keratoplasty (corneal transplant); endothelial | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 65778 | Placement of amniotic membrane on the ocular surface; without sutures | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 65779 | Placement of amniotic membrane on the ocular surface; single layer, sutured | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 65780 | Ocular surface reconstruction; amniotic membrane transplantation, multiple layers | Standard Local Prior Authorization Code List, Pg 29 Original policy |
| 65855 | Trabeculoplasty by laser surgery, 1 or more sessions (defined treatment series) | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 66761 | Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (per session) | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 66840 | Removal of lens material; aspiration technique, 1 or more stages | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 66850 | Removal, Lens Material; Phacofragmentation, W/Aspiration | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 66852 | Removal, Lens Material; Pars Plana Approach, W/Wo Vitrectomy | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 66985 | Insertion, Intraocular Lens Prosthesis (Secondary Implant) (No Concurrent Cataract Removal) | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 66988 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsif | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 67010 | Removal, Vitreous, Anterior Approach; Subtotal Removal W/Mech Vitrectomy | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 67028 | Intravitreal Injection, A Pharmacologic Agent (Sep Proc) | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 67218 | Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; radiation by implantation of source (includes removal of source) | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 67345 | Chemodenervation, Extraocular Muscle | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 67973 | Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, lower | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 68320 | Conjunctivoplasty; W/Conjunctival Graft/Extensive Rearrangement | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 68700 | Plastic Repair, Canaliculi | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 69705 | Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); unilateral | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 69706 | Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); bilateral | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 70336 | Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 70450 | Computed tomography, head or brain; without contrast material | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 70460 | Computed tomography, head or brain; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 70470 | Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 70471 | Computed tomographic angiography (CTA), head and neck, with contrast material(s), including noncontrast images, when performed, and image postprocessing | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 70473 | Computed tomographic (CT) cerebral perfusion analysis with contrast material(s), including image postprocessing performed without concurrent CT or CT angiography of the same anatomy | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 70480 | Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 70481 | Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 30 Original policy |
| 70482 | Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70486 | Computed tomography, maxillofacial area; without contrast material | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70487 | Computed tomography, maxillofacial area; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70488 | Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70490 | Computed tomography, soft tissue neck; without contrast material | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70491 | Computed tomography, soft tissue neck; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70492 | Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70496 | Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70498 | Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70540 | Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s) | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70542 | Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70543 | Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70544 | Magnetic resonance angiography, head; without contrast material(s) | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70545 | Magnetic resonance angiography, head; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70546 | Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences | Standard Local Prior Authorization Code List, Pg 31 Original policy |