Anthem Blue Cross Blue Shield of Georgia prior authorization, page 30
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 |
|---|---|---|
| 0613U | Oncology (urothelial carcinoma), DNA methylation and mutation analysis of 6 biomarkers (TWIST1, OTX1, ONECUT2, FGFR3, HRAS, TERT promoter region), methylation-specific PCR and targeted next- generation sequencing, urine, algorithm reported as a probability index for bladder cancer and upper tract urothelial carcinoma | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0614T | Removal and replacement of substernal implantable defibrillator pulse generator | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0627T | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level [VAST, Via Disc] | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0628U | Nephrology (kidney disease-related genetic conditions), genomic analysis, renal disease panel, saliva, DNA, next-generation sequencing of 449 genes, reported as pathogenic or likely pathogenic variants of uncertain significance or risk alleles | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0629T | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level [VAST, Via Disc] | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0630U | Oncology (breast), mRNA, gene expression profiling by microarray of 80 genes (80 content and 465 housekeeping), utilizing formalin-fixed paraffin- embedded tissue (FFPE), algorithm reported as an index that is diagnostic of a molecular subtype (luminal, basal, Her2) | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0633T | Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast material | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0634T | Computed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0635T | Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s) | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0636T | Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s) | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0637T | Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s) | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0638T | Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s) | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0648T | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmissio | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0652T | Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0653T | Esophagogastroduodenoscopy, flexible, transnasal; with biopsy, single or multiple | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0654T | Esophagogastroduodenoscopy, flexible, transnasal; with insertion of intraluminal tube or catheter | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0673T | Ablation, benign thyroid nodule(s), percutaneous, laser, including imaging guidance | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0701T | Molecular fluorescent imaging of suspicious nevus; each additional lesion (List separately in addition to code for primary procedure) | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0707T | Injection(s), bone substitute material (eg, calcium phosphate) into subchondral bone defect (ie, bone marrow lesion, bone bruise, stress injury, microtrabecular fracture), including imaging guidance and arthroscopic assistance for joint visualization | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0767T | Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, with identification and mapping of the treatment location, including noninvasive electroneurographic localization (nerve conduction localization), when performed; each additional nerve (List separately in addition to code for primary procedure) | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0770T | Virtual reality technology to assist therapy (List separately in addition to code for primary procedure) | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0772T | Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of dissociation or consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service) | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0774T | Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service) | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0787T | Revision or removal of neurostimulator electrode array, sacral, with integrated neurostimulator | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0816T | Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (eg, array or leadless), and pulse generator or receiver, including analysis, programming, and imaging guidance, when performed, posterior tibial nerve; subcutaneous | Standard Local Prior Authorization Code List, Pg 81 Original policy |
| 0817T | Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (eg, array or leadless), and pulse generator or receiver, including analysis, programming, and imaging guidance, when performed, posterior tibial nerve; subfascial | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0818T | Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subcutaneous | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0819T | Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subfascial | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0823T | Transcatheter insertion of permanent single- chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0824T | Transcatheter removal of permanent single- chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography), when performed | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0825T | Transcatheter removal and replacement of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography) and device evaluation (eg, interrogation or programming), when performed | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0908T | Open implantation of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0909T | Replacement of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0910T | Removal of integrated neurostimulation system, vagus nerve | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0911T | Electronic analysis of implanted integrated neurostimulation system, vagus nerve; without programming by physician or other qualified health care professional | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0912T | Electronic analysis of implanted integrated neurostimulation system, vagus nerve; with simple programming by physician or other qualified health care professional | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0913T | Percutaneous transcatheter therapeutic drug delivery by intracoronary drugdelivery balloon (eg, drug-coated, drug-eluting), including mechanical dilation by nondrug-delivery | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0966T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; dual arch, with additional mandibular advancement | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0970T | Ablation, benign breast tumor (eg, fibroadenoma), percutaneous, laser, including imaging guidance when performed, each tumor | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| 0971T | Ablation, malignant breast tumor(s), percutaneous, laser, including imaging guidance when performed, unilateral | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| A4100 | Skin substitute, FDA-cleared as a device, not otherwise specified | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| A4540 | Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| A4543 | Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| A4544 | Electrode for external lower extremity nerve stimulator for restless legs syndrome | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| A4545 | Supplies and accessories for external tibial nerve stimulator (e.g., socks, gel pads, electrodes, etc.), needed for one month | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| A4604 | Tubing with integrated heating element for use with positive airway pressure device | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| A7027 | Combination oral/nasal mask, used with continuous positive airway pressure | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| A7028 | Oral cushion for combination oral/nasal mask, replacement only, each | Standard Local Prior Authorization Code List, Pg 82 Original policy |
| A7029 | Nasal pillows for combination oral/nasal mask, replacement only, pair | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A7030 | Full face mask used with positive airway pressure device, each | Standard Local Prior Authorization Code List, Pg 83 Original policy |