Anthem Blue Cross Blue Shield of Georgia prior authorization, page 23
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 |
|---|---|---|
| 93654 | Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3- dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of ventricular tachycardia or focus of ventricular ectopy including left ventricular pacing and recording, when performed | Standard Local Prior Authorization Code List, Pg 58 Original policy |
| 93656 | Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3-dimensional mapping, intracardiac echocardiography including imaging supervision and interpretation, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, right ventricular pacing/recording, and His bundle recording, when performed | Standard Local Prior Authorization Code List, Pg 58 Original policy |
| 93657 | Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation | Standard Local Prior Authorization Code List, Pg 58 Original policy |
| 93880 | Duplex scan of extracranial arteries; complete bilateral study | Standard Local Prior Authorization Code List, Pg 58 Original policy |
| 93882 | Duplex scan of extracranial arteries; unilateral or limited study | Standard Local Prior Authorization Code List, Pg 58 Original policy |
| 93922 | Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1- 2 levels) | Standard Local Prior Authorization Code List, Pg 58 Original policy |
| 93923 | Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with reactive hyperemia) | Standard Local Prior Authorization Code List, Pg 58 Original policy |
| 93924 | Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 93925 | Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 93926 | Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 93930 | Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 93931 | Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 93978 | Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 93979 | Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 94667 | Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95782 | Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95783 | Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95800 | Sleep study, unattended, simultaneous recording; heart rate, oxygen, Saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95801 | Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen, Saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone) | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95805 | Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95806 | Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95807 | Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95808 | Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95810 | Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95811 | Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95921 | Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95923 | Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95965 | Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (eg, epileptic cerebral cortex localization) | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 95966 | Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, single modality (eg, sensory, motor, language, or visual cortex localization) | Standard Local Prior Authorization Code List, Pg 59 Original policy |
| 96001 | Comprehensive computer-based motion analysis by video-taping and 3D kinematics; with dynamic plantar pressure measurements during walking | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 96934 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each additional lesion (List separately in addition to code for primary procedure) | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 96935 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, each additional lesion (List separately in addition to code for primary procedure) | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 96936 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, each additional lesion (List separately in addition to code for primary procedure) | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97010 | Application of a modality to 1 or more areas; hot or cold packs | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97012 | Application of a modality to 1 or more areas; traction, mechanical | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97014 | Application of a modality to 1 or more areas; electrical stimulation (unattended) | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97016 | Application of a modality to 1 or more areas; vasopneumatic devices | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97018 | Application of a modality to 1 or more areas; paraffin bath | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97022 | Application of a modality to 1 or more areas; whirlpool | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97024 | Application of a modality to 1 or more areas; diathermy (eg, microwave) | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97026 | Application of a modality to 1 or more areas; infrared | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97028 | Application of a modality to 1 or more areas; ultraviolet | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97032 | Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97033 | Application of a modality to 1 or more areas; iontophoresis, each 15 minutes | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97034 | Application of a modality to 1 or more areas; contrast baths, each 15 minutes | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97035 | Application of a modality to 1 or more areas; ultrasound, each 15 minutes | Standard Local Prior Authorization Code List, Pg 60 Original policy |
| 97036 | Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes | Standard Local Prior Authorization Code List, Pg 61 Original policy |
| 97110 | Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility | Standard Local Prior Authorization Code List, Pg 61 Original policy |
| 97112 | Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities | Standard Local Prior Authorization Code List, Pg 61 Original policy |
| 97113 | Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises | Standard Local Prior Authorization Code List, Pg 61 Original policy |