Anthem Blue Cross Blue Shield of Georgia prior authorization, page 15
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 |
|---|---|---|
| 77049 | 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; bilateral | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77078 | Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77084 | Magnetic resonance (eg, proton) imaging, bone marrow blood supply | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77295 | 3-dimensional radiotherapy plan, including dose- volume histograms | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77301 | Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77316 | Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s) | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77317 | Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s) | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77318 | Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77338 | Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77370 | Special medical radiation physics consultation | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77371 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi- source Cobalt 60 based | Standard Local Prior Authorization Code List, Pg 36 Original policy |
| 77372 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77373 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77387 | Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77402 | Radiation treatment delivery, =• 1 MeV; simple | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77407 | Radiation treatment delivery, =• 1 MeV; intermediate | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77412 | Radiation treatment delivery, =• 1 MeV; complex | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77424 | Intraoperative radiation treatment delivery, x-ray, single treatment session | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77425 | Intraoperative radiation treatment delivery, electrons, single treatment session | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77432 | Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77435 | Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77436 | Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation- aided field setting | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77437 | Surface radiation therapy; superficial, delivery, =150 kV, per fraction (eg, electronic brachytherapy) | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77438 | Surface radiation therapy; orthovoltage, delivery, >150-500 kV, per fraction | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77439 | Surface radiation therapy; superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for treatment of cutaneous tumors, per course of treatment (List separately in addition to code for primary procedure) | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77469 | Intraoperative radiation treatment management | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77470 | Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation) | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77520 | Proton treatment delivery; simple, without compensation | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77522 | Proton treatment delivery; simple, with compensation | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77523 | Proton treatment delivery; intermediate | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77525 | Proton treatment delivery; complex | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77761 | Intracavitary radiation source application; simple | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77762 | Intracavitary radiation source application; intermediate | Standard Local Prior Authorization Code List, Pg 37 Original policy |
| 77763 | Intracavitary radiation source application; complex | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 77770 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 77771 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 77772 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 77778 | Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 77790 | Supervision, handling, loading of radiation source | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 78429 | Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 78430 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 78431 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 78432 | Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability) | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 78433 | Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently acquired computed tomography transmission scan | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 78451 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 78452 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 78453 | Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 78454 | Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 78459 | Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study | Standard Local Prior Authorization Code List, Pg 38 Original policy |
| 78466 | Myocardial imaging, infarct avid, planar; qualitative or quantitative | Standard Local Prior Authorization Code List, Pg 39 Original policy |