Anthem Blue Cross Blue Shield of Georgia prior authorization, page 2
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 |
|---|---|---|
| 22224 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22226 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22505 | Manipulation of spine requiring anesthesia, any region | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22510 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging, Guidance; cervicothoracic | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22511 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22512 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22513 | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22514 | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22515 | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22527 | Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22532 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22533 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | Standard Local Prior Authorization Code List, Pg 3 Original policy |
| 22534 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22551 | Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22552 | Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22554 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22556 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22558 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22585 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22590 | Arthrodesis, posterior technique, craniocervical (occiput-C2) | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22595 | Arthrodesis, posterior technique, atlas-axis (C1-C2) | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22600 | Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22610 | Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed) | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22612 | Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22614 | Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22630 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22632 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar; each additional interspace | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22633 | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22634 | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace, lumbar; each additional interspace | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22800 | Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22802 | Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22804 | Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22808 | Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22810 | Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22830 | Exploration of spinal fusion | Standard Local Prior Authorization Code List, Pg 4 Original policy |
| 22840 | Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22841 | Internal spinal fixation by wiring of spinous processes | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22842 | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22843 | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22844 | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22845 | Anterior instrumentation; 2 to 3 vertebral segments | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22846 | Anterior instrumentation; 4 to 7 vertebral segments | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22847 | Anterior instrumentation; 8 or more vertebral segments | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22848 | Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22849 | Reinsertion of spinal fixation device | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22853 | Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22854 | Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22856 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22857 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); single interspace, lumbar | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22858 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical | Standard Local Prior Authorization Code List, Pg 5 Original policy |