Anthem Blue Cross Blue Shield of Georgia prior authorization, page 35
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 |
|---|---|---|
| J9350 | Injection, mosunetuzumab-axgb, 1 mg [Lunsumio] | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9353 | Injection, margetuximab-cmkb, 5 m | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9358 | Injection, fam-trastuzumab deruxtecan-nxki, 1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9359 | Injection, loncastuximab tesirine-lpyl, 0.075 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9380 | Injection, teclistamab-cqyv, 0.5 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9382 | Injection, zenocutuzumab-zbco, 1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9400 | Injection, ziv-aflibercept, 1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9601 | Injection, linvoseltamab-gcpt, 1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| K1027 | Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| L8694 | Auditory osseointegrated device, transducer/actuator, replacement only, each | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q3001 | Radioelements for brachytherapy, any type, each | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4101 | Apligraf, per sq cm | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4102 | Oasis wound matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4104 | Integra bilayer matrix wound dressing (bmwd), per square centimeter | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4105 | Integra Dermal Regeneration Template (DRT) or Integra Omnigraft dermal regeneration matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4107 | Graftjacket, per square centimeter | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4110 | Primatrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4115 | Alloskin, per square centimeter | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4116 | AlloDerm, per sq cm | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4121 | Theraskin, per square centimeter | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4122 | DermACELL, DermACELL AWM or DermACELL AWM Porous, per sq cm | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4124 | OASIS ultra tri-layer wound matrix, per sq cm | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4128 | FlexHD, or AllopatchHD, per sq cm | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4130 | Strattice, per sq cm | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4133 | Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4151 | AmnioBand or Guardian, per sq cm | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4154 | Biovance, per square centimeter [for diabetic foot ulcers only] | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4158 | Kerecis Omega3, per sq cm | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4160 | NuShield, per square centimeter | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4186 | Epifix, per sq cm | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4187 | Epicord, per sq cm | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4283 | Biovance Tri-Layer or Biovance 3L, per sq cm | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4334 | Amnioplast 1, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4335 | Amnioplast 2, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q4369 | Amnioplast 3, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q5112 | Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q5113 | Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q5114 | Injection, trastuzumab-dkst, biosimilar, (Ogivri), 10 mg | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q5116 | Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q5146 | Injection, trastuzumab-strf (Hercessi), biosimilar, 10 mg(cid:9) | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q5160 | Injection, bevacizumab-nwgd (jobevne), biosimilar, 10 mg | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q5161 | Injection, denosumab-kyqq (aukelso/bosaya), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q5162 | Injection, denosumab-nxxp (bildyos/bilprevda), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| Q5165 | Injection, denosumab-mobz (oziltus), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| S0353 | Treatment planning and care coordination management for cancer initial treatment | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| S0354 | Treatment planning and care coordination management for cancer established patient with a change of regimen | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| S2112 | Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte, Cells) | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| S2118 | Metal-on-metal total hip resurfacing, including acetabular and femoral components | Standard Local Prior Authorization Code List, Pg 90 Original policy |
| S2202 | Echosclerotherapy | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S2342 | Nasal endoscopy for postoperative debridement following functional endoscopic sinus surgery, nasal and/or sinus cavity(s), unilateral or bilateral | Standard Local Prior Authorization Code List, Pg 91 Original policy |