Anthem Blue Cross Blue Shield of Georgia prior authorization, page 36
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 |
|---|---|---|
| S3800 | Genetic testing for amyotrophic lateral sclerosis (ALS) | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3840 | DNA analysis for germline mutations of the RET proto-oncogene for susceptibility to multiple endocrine neoplasia type 2 | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3841 | Genetic testing for retinoblastoma | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3842 | Genetic testing for Von Hippel-Lindau disease | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3844 | DNA analysis of the connexin 26 gene (GJB2) for susceptibility to congenital, profound deafness | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3845 | Genetic testing for alpha-thalassemia | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3846 | Genetic testing for hemoglobin E beta-thalassemia | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3849 | Genetic testing for Niemann-Pick disease | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3850 | Genetic testing for sickle cell anemia | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3852 | DNA analysis for APOE epsilon 4 allele for susceptibility to Alzheimer's disease | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3853 | Genetic testing for myotonic muscular dystrophy | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3854 | Gene expression profiling panel for use in the management of breast cancer treatment | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3861 | Genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and variants for suspected Brugada Syndrome | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3865 | Comprehensive gene sequence analysis for hypertrophic cardiomyopathy | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3866 | Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mu | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S3870 | Comparative genomic hybridization (CGH) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S8030 | Scleral application of tantalum ring(s) for localization of lesions for proton beam therapy | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S8948 | Application of a modality (requiring constant care provider attendance) to one or more areas; low- level laser; each 15 minutes | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S8950 | Complex lymphedema therapy, each 15 minutes | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S8990 | Physical or manipulative therapy performed for maintenance rather than restoration | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| S9152 | Speech therapy, re-evaluation | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| V2790 | Amniotic membrane for surgical reconstruction, per procedure | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| V5298 | Hearing aid, not otherwise classified | Standard Local Prior Authorization Code List, Pg 91 Original policy |
| V5362 | Speech Screening | Standard Local Prior Authorization Code List, Pg 92 Original policy |
| V5363 | Language Screening | Standard Local Prior Authorization Code List, Pg 92 Original policy |
| V5364 | Dysphagia Screening | Standard Local Prior Authorization Code List, Pg 92 Original policy |
| 00580 | Anesthesia for heart transplant or heart/lung transplant | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 00796 | Anesthesia, Intraperitoneal Proc, Upper Abdomen, W/Laparoscopy; Liver Transplant, Recipient | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 00868 | Anesthesia, Extraperitoneal Proc, Lower Abdomen, W/Urinary Tract; Renal Transplant, Recipient | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 15825 | Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 15828 | Rhytidectomy; cheek, chin, and neck | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 15829 | Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 15832 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 15833 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 15834 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 15835 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 15836 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 15837 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 15838 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 15839 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 15840 | Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) | Standard Local Prior Authorization Code List, Pg 93 Original policy |
| 15841 | Graft for facial nerve paralysis; free muscle graft (including obtaining graft) | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 15842 | Graft for facial nerve paralysis; free muscle flap by microsurgical technique | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 15845 | Graft for facial nerve paralysis; regional muscle transfer | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 15876 | Suction assisted lipectomy; head and neck | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 15878 | Suction assisted lipectomy; upper extremity | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 15879 | Suction assisted lipectomy; lower extremity | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 17999 | Unlisted procedure, skin, mucous membrane and subcutaneous tissue | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 19303 | Mastectomy , simple, complete | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 19316 | Mastopexy | Standard Local Prior Authorization Code List, Pg 94 Original policy |