Anthem Blue Cross Blue Shield of Georgia prior authorization, page 33
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 |
|---|---|---|
| G0400 | Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| G0448 | Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac venous system, for left ventricular pacing | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| G0458 | Low dose rate (LDR) prostate brachytherapy services, composite rate | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| G9143 | Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s) | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| G9840 | RAS (KRAS and NRAS) gene mutation testing performed before initiation of anti-EGFR MoAb | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| G9841 | RAS (KRAS and NRAS) gene mutation testing not performed before initiation of anti-EGFR MoAb | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J0208 | Injection, sodium thiosulfate (Pedmark), 100 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J0614 | Injection, treosulfan, 50 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J0641 | Injection, levoleucovorin, 0.5 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J0642 | Injection, levoleucovorin (khapzory), 0.5 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J0870 | Injection, imetelstat, 1 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J1323 | Injection, elranatamab-bcmm, 1 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J1326 | Injection, zolbetuximab-clzb, 2 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J1448 | Injection, trilaciclib, 1 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J1454 | Injection, fosnetupitant 235 mg and palonosetron 0.25 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J2277 | Injection, motixafortide, 0.25 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J2787 | Riboflavin 5'-phosphate, ophthalmic solution, up to 3 ml | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J3055 | Injection, talquetamab-tgvs, 0.25 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J3263 | Injection, toripalimab-tpzi, 1 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J7330 | Autologous cultured chondrocytes, implant | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J9011 | Injection, datopotamab deruxtecan-dlnk, 1 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J9015 | Injection, aldesleukin, per single use vial | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J9021 | Injection, asparaginase, recombinant, (rylaze), 0.1 mg | Standard Local Prior Authorization Code List, Pg 87 Original policy |
| J9022 | Injection, atezolizumab, 10 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9023 | Injection, avelumab, 10 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9024 | Injection, atezolizumab, 5 mg and hyaluronidase- tqjs | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9026 | Injection, tarlatamab-dlle, 1 mg(cid:9) | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9028 | Injection, nogapendekin alfa inbakicept-pmln, for intravesical use, 1 mcg(cid:9) | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9029 | Injection, nadofaragene firadenovec-vncg, per therapeutic dose [Adstiladrin] | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9032 | Injection, belinostat, 10 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9039 | Injection, blinatumomab, 1 microgram | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9042 | Injection, brentuximab vedotin, 1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9047 | Injection, carfilzomib, 1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9053 | Injection, belantamab mafodotin-blmf, 0.1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9055 | Injection, cetuximab, 10 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9057 | Injection, copanlisib, 1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9061 | Injection, amivantamab-vmjw, 2 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9062 | Injection, amivantamab 5 mg and hyaluronidase- lpuj | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9063 | Injection, mirvetuximab soravtansine-gynx, 1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9064 | Inj, cabazitaxel (Sandoz) | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9118 | Injection, calaspargase pegol-mknl, 10 units | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9119 | Injection, cemiplimab-rwlc, 1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9144 | Injection, daratumumab, 10 mg and hyaluronidase- fihj | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9145 | Injection, daratumumab, 10 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9161 | Injection, denileukin diftitox-cxdl, 1 mcg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9173 | Injection, durvalumab, 10 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9176 | Injection, elotuzumab, 1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9177 | Injection, enfortumab vedotin-ejfv, 0.25 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9179 | Injection, eribulin mesylate, 0.1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9183 | Gemcitabine intravesical system, 225 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |