Anthem Blue Cross Blue Shield of Georgia prior authorization, page 3
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 |
|---|---|---|
| 22859 | Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22860 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (List separa | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22861 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22862 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22864 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22865 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22868 | Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level | Standard Local Prior Authorization Code List, Pg 5 Original policy |
| 22870 | Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23105 | Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23107 | Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23120 | Claviculectomy; Partial | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23130 | Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23410 | Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23412 | Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23415 | Coracoacromial ligament release, with or without acromioplasty | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23420 | Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23430 | Tenodesis of long tendon of biceps | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23440 | Resection or transplantation of long tendon of biceps | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23450 | Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23455 | Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure) | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23460 | Capsulorrhaphy, anterior, any type; with bone block | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23462 | Capsulorrhaphy, anterior, any type; with coracoid process transfer | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23465 | Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23466 | Capsulorrhaphy, glenohumeral joint, any type multi- directional instability | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23470 | Arthroplasty, glenohumeral joint; hemiarthroplasty | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23472 | Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23473 | Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23474 | Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 23700 | Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 24300 | Manipulation, elbow, under anesthesia | Standard Local Prior Authorization Code List, Pg 6 Original policy |
| 25259 | Manipulation, wrist, under anesthesia | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 26340 | Manipulation, finger joint, under anesthesia, each joint | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27096 | Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27120 | Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type) | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27122 | Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure) | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27125 | Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27130 | Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27132 | Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27134 | Revision of total hip arthroplasty; both components, with or without autograft or allograft | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27137 | Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27138 | Revision of total hip arthroplasty; femoral component only, with or without allograft | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27275 | Manipulation, hip joint, requiring general anesthesia | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27279 | Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixation device | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27280 | Arthrodesis, sacroiliac joint, open, includes obtaining bone graft, including instrumentation, when performed | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27331 | Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27332 | Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27333 | Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27334 | Arthrotomy, with synovectomy, knee; anterior OR posterior | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27335 | Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27345 | Excision of synovial cyst of popliteal space (eg, Baker's cyst) | Standard Local Prior Authorization Code List, Pg 7 Original policy |