Anthem Blue Cross Blue Shield of Georgia prior authorization, page 31
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 |
|---|---|---|
| A7031 | Face mask interface, replacement for full face mask, each | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A7032 | Cushion for use on nasal mask interface, replacement only, each | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A7033 | Pillow for use on nasal cannula type interface, replacement only, pair | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A7034 | Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A7035 | Headgear used with positive airway pressure device | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A7036 | Chinstrap used with positive airway pressure device | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A7037 | Tubing used with positive airway pressure device | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A7038 | Filter, disposable, used with positive airway pressure device | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A7039 | Filter, nondisposable, used with positive airway pressure device | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A7044 | Oral interface used with positive airway pressure device, each | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A7045 | Exhalation port with or without swivel used with accessories for positive airway devices, replacement only | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A7046 | Water chamber for humidifier, used with positive airway pressure device, replacement, each | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A9513 | Lutetium Lu 177, dotatate, therapeutic, 1 mCi | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A9543 | Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A9606 | Radium ra-223 dichloride, therapeutic, per microcurie | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A9607 | Lutetium Lu 177 vipivotide tetraxetan, therapeutic, 1 mCi | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| A9616 | Gallium Ga-68 gozetotide (Gozellix), diagnostic, 1 mCi | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| C1605 | Pacemaker, leadless, dual chamber (right atrial and right ventricular implantable components), rate- responsive, including all necessary components for implantation | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| C1721 | Cardioverter-defibrillator, dual chamber (implantable) | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| C1722 | Cardioverter-defibrillator, single chamber (implantable) | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| C1726 | Catheter, balloon dilatation, nonvascular | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| C1764 | Event recorder, cardiac (implantable) | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| C1772 | Infusion pump, programmable (implantable) | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| C1777 | Lead, cardioverter-defibrillator, endocardial single coil (implantable) | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| C1785 | Pacemaker, dual chamber, rate-responsive (implantable) | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| C1786 | Pacemaker, single chamber, rate-responsive (implantable) | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| C1813 | Prosthesis, penile, inflatable | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| C1816 | Receiver and/or transmitter, neurostimulator (implantable) | Standard Local Prior Authorization Code List, Pg 83 Original policy |
| C1823 | Generator, neurostimulator (implantable), nonrechargeable, with transvenous sensing and stimulation leads | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C1832 | Autograft suspension, including cell processing and application, and all system components | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C1882 | Cardioverter-defibrillator, other than single or dual chamber (implantable) | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C1883 | Adapter/extension, pacing lead or neurostimulator lead (implantable) | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C1895 | Lead, cardioverter-defibrillator, endocardial dual coil (implantable) | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C1896 | Lead, cardioverter-defibrillator, other than endocardial single or dual coil (implantable) | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C2619 | Pacemaker, dual chamber, nonrate-responsive (implantable) | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C2621 | Pacemaker, other than single or dual chamber (implantable) | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C2626 | Infusion pump, nonprogrammable, temporary (implantable) | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C7513 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C7514 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C7515 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C7517 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, with iliac and/or femoral artery angiography, nonselective, bilateral or ipsilateral to catheter insertion, performed at the same time as cardiac catheterization and/or coronary angiography, includes positioning or placement of the catheter in the distal aorta or ipsilateral femoral or iliac artery, injection of dye, production of permanent images, and radiologic supervision and interpretation | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C7552 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization with intravascular doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress, initial vessel | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C7553 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography with pharmacologic agent administration (e.g., inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after and repeat pharmacologic agent administration, when performed | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C8002 | Preparation of skin cell suspension autograft, automated, including all enzymatic processing and device components (do not report with manual suspension preparation) | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C8903 | Magnetic resonance imaging with contrast, breast; unilateral | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C8905 | Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral | Standard Local Prior Authorization Code List, Pg 84 Original policy |
| C8906 | Magnetic resonance imaging with contrast, breast; bilateral | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C8908 | Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9358 | Dermal substitute, native, non-denatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 square centimeters | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9359 | Porous purified collagen matrix bone void filler (Integra Mozaik Osteoconductive Scaffold Putty, Integra OS Osteoconductive Scaffold Putty), per 0.5 cc | Standard Local Prior Authorization Code List, Pg 85 Original policy |