Anthem Blue Cross Blue Shield of Georgia prior authorization, page 13
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 |
|---|---|---|
| 70547 | Magnetic resonance angiography, neck; without contrast material(s) | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70548 | Magnetic resonance angiography, neck; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70549 | Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70551 | Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70552 | Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70553 | Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70554 | Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration | Standard Local Prior Authorization Code List, Pg 31 Original policy |
| 70555 | Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 71250 | Computed tomography, thorax, diagnostic; without contrast material | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 71260 | Computed tomography, thorax, diagnostic; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 71270 | Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further sections | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 71271 | Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 71275 | Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 71550 | Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 71551 | Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s) | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 71552 | Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 71555 | Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 72125 | Computed tomography, cervical spine; without contrast material | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 72126 | Computed tomography, cervical spine; with contrast material | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 72127 | Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 72128 | Computed tomography, thoracic spine; without contrast material | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 72129 | Computed tomography, thoracic spine; with contrast material(cid:9) | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 72130 | Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 72131 | Computed tomography, lumbar spine; without contrast material | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 72132 | Computed tomography, lumbar spine; with contrast material | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 72133 | Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 72141 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 72142 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 72146 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material | Standard Local Prior Authorization Code List, Pg 32 Original policy |
| 72147 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72148 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72149 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72156 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72157 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72158 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72159 | Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s) | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72191 | Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72192 | Computed tomography, pelvis; without contrast material | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72193 | Computed tomography, pelvis; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72194 | Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72195 | Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s) | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72196 | Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72197 | Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72198 | Magnetic resonance angiography, pelvis, with or without contrast material(s) | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 72295 | Discography, lumbar, radiological supervision and interpretation | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 73200 | Computed tomography, upper extremity; without contrast material | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 73201 | Computed tomography, upper extremity; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 73202 | Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 73206 | Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed | Standard Local Prior Authorization Code List, Pg 33 Original policy |
| 73218 | Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s) | Standard Local Prior Authorization Code List, Pg 33 Original policy |