Anthem Blue Cross Blue Shield of Georgia prior authorization, page 32
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 |
|---|---|---|
| C9362 | Porous purified collagen matrix bone void filler (Integra Mozaik Osteoconductive Scaffold Strip), per 0.5 cc | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9363 | Skin substitute (Integra Meshed Bilayer Wound Matrix), per sq cm | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9600 | Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9601 | Percutaneous transcatheter placement of drug- eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (list | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9602 | Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9603 | Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary art | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9604 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9605 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9607 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluti | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9608 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluti | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9764 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, includes angioplasty within the sam | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9765 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, and transluminal stent placement(s) | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9766 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and atherectomy, includes angioplast | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9767 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and transluminal stent placement(s) | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9772 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy, includes angioplasty within the same vessel (s), when perfo | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9773 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9774 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9775 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includ | Standard Local Prior Authorization Code List, Pg 85 Original policy |
| C9781 | Arthroscopy, shoulder, surgical; with implantation of subacromial spacer (e.g., balloon), includes debridement (e.g., limited or extensive), subacromial decompression, acromioplasty, and biceps tenodesis when performed | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| D9222 | Deep sedation/general anesthesia - first 15 minutes | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| D9223 | Deep sedation/general anesthesia - each 15 minute increments | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| D9950 | Occlusion Analysis - Mounted Case | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| D9951 | Occlusal Adjustment - Limited | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| D9952 | Occlusal Adjustment - Complete | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0470 | Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0471 | Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0485 | Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0486 | Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0491 | Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by hardware remote, 90- day supply | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0492 | Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, controlled by phone application | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0493 | Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by phone application, 90- day supply | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0530 | Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any type | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0561 | Humidifier, nonheated, used with positive airway pressure device | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0562 | Humidifier, heated, used with positive airway pressure device | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0601 | Continuous positive airway pressure (CPAP) device | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0616 | Implantable cardiac event recorder with memory, activator, and programmer | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0736 | Transcutaneous tibial nerve stimulator | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0737 | Transcutaneous tibial nerve stimulator, controlled by phone application | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0743 | External lower extremity nerve stimulator for restless legs syndrome, each | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| E0748 | Osteogenesis stimulator, electrical, noninvasive, spinal applications | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| G0260 | Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| G0277 | Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| G0283 | Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care | Standard Local Prior Authorization Code List, Pg 86 Original policy |
| G0289 | Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| G0295 | Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| G0330 | Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating room | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| G0339 | Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| G0340 | Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| G0398 | Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| G0399 | Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation | Standard Local Prior Authorization Code List, Pg 87 Original policy |