Anthem Blue Cross Blue Shield of Georgia prior authorization, page 37
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 |
|---|---|---|
| 19325 | Breast augmentation with implant | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 19328 | Removal of intact breast implant | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 19330 | Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel) | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 19340 | Insertion of breast implant on same day of mastectomy (ie, immediate) | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 19342 | Insertion or replacement of breast implant on separate day from mastectomy | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 19350 | Nipple/areola reconstruction | Standard Local Prior Authorization Code List, Pg 94 Original policy |
| 19355 | Correction of inverted nipples | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 19357 | Tissue expander placement in breast reconstruction, including subsequent expansion(s) | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 19361 | Breast reconstruction; with latissimus dorsi flap | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 19364 | Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap) | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 19367 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 19368 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging) | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 19369 | Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 19380 | Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction) | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 19396 | Preparation of moulage for custom breast implant | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 20999 | Unlisted procedure, musculoskeletal system, general | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 21083 | Impression and custom preparation; palatal lift prosthesis | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 21086 | Impression and custom preparation; auricular prosthesis | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 21087 | Impression and custom preparation; nasal prosthesis | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 21137 | Reduction forehead; contouring only | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 21138 | Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) | Standard Local Prior Authorization Code List, Pg 95 Original policy |
| 21139 | Reduction forehead; contouring and setback of anterior frontal sinus wall | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21145 | Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21146 | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21147 | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21151 | Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts) | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21154 | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21155 | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21159 | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21160 | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21172 | Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21175 | Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21179 | Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21180 | Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21182 | Reconstruction, Orbit/Forehead/Nasoethmoid, Following Excision, Benign Tumor, Graft < 40 Sq Cm | Standard Local Prior Authorization Code List, Pg 96 Original policy |
| 21183 | Reconstruction, Orbit/Forehead/Nasoethmiod, Following Excision, Benign Tumor, Graft 40-80 Sq Cm | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 21188 | Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 21230 | Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 21235 | Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 21247 | Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia) | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 21255 | Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 21256 | Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia) | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 21270 | Malar augmentation, prosthetic material | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 21275 | Secondary Revision, Orbitocraniofacial Reconstruction | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 21740 | Reconstructive repair of pectus excavatum or carinatum; open | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 21742 | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 21743 | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 22999 | Unlisted procedure, abdomen, musculoskeletal system | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 27599 | Unlisted procedure, femur or knee | Standard Local Prior Authorization Code List, Pg 97 Original policy |
| 28899 | Unlisted procedure, foot or toes | Standard Local Prior Authorization Code List, Pg 97 Original policy |