Anthem Blue Cross Blue Shield of Georgia prior authorization, page 14
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 |
|---|---|---|
| 73219 | Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73220 | Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73221 | Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73222 | Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73223 | Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73225 | Magnetic resonance angiography, upper extremity, with or without contrast material(s) | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73700 | Computed tomography, lower extremity; without contrast material | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73701 | Computed tomography, lower extremity; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73702 | Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73706 | Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73718 | Mri, Lower Extremity Other Than Joint; W/O Contrast Matl(S) | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73719 | Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73720 | Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73721 | Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73722 | Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73723 | Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 73725 | Magnetic resonance angiography, lower extremity, with or without contrast material(s) | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 74150 | Computed tomography, abdomen; without contrast material | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 74160 | Computed tomography, abdomen; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 74170 | Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 74174 | Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 74175 | Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing | Standard Local Prior Authorization Code List, Pg 34 Original policy |
| 74176 | Computed tomography, abdomen and pelvis; without contrast material | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 74177 | Computed tomography, abdomen and pelvis; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 74178 | Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 74181 | Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 74182 | Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 74183 | Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 74185 | Magnetic resonance angiography, abdomen, with or without contrast material(s) | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 74261 | Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 74262 | Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 74263 | Computed tomographic (CT) colonography, screening, including image postprocessing | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 74712 | Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single of first gestation | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 75557 | Cardiac magnetic resonance imaging for morphology and function without contrast material | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 75559 | Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 75561 | Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 75563 | Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 75571 | Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 75572 | Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 75573 | Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of left ventricular [LV] cardiac function, right ventricular [RV] structure and function and evaluation of vascular structures, if performed) | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 75574 | Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) | Standard Local Prior Authorization Code List, Pg 35 Original policy |
| 75580 | Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of the data set from a coronary computed tomography angiography, with interpretation and report by a physician or other qualified health care professional | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 75635 | Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 76390 | Magnetic resonance spectroscopy | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 76391 | Magnetic resonance (eg, vibration) elastography | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 76873 | Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure) | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 76965 | Ultrasonic guidance for interstitial radioelement application | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77046 | Magnetic resonance imaging, breast, without contrast material; unilateral | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77047 | Magnetic resonance imaging, breast, without contrast material; bilateral | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77048 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral | Standard Local Prior Authorization Code List, Pg 36 Original policy |