Anthem Blue Cross Blue Shield of Georgia prior authorization, page 39
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 |
|---|---|---|
| 38240 | Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 38241 | Hematopoietic progenitor cell (HPC); autologous transplantation | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 38242 | Allogeneic lymphocyte infusions | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 38243 | Hematopoietic progenitor cell (HPC); HPC boost | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 38999 | Unlisted procedure, hemic or lymphatic system | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 43332 | Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 43333 | Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 43334 | Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or other prosthesis | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 43335 | Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; with implantation of mesh or other prosthesis | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 43336 | Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 43337 | Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; with implantation of mesh or other prosthesis | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 43631 | Gastrectomy, Partial, Distal; W/Gastroduodenostomy | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 43632 | Gastrectomy, Partial, Distal; W/Gastrojejunostomy | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 43633 | Gastrectomy, partial, distal; with Roux-en-Y reconstruction | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 43644 | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) | Standard Local Prior Authorization Code List, Pg 100 Original policy |
| 43645 | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 43771 | Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 43775 | Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 43843 | Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical- banded gastroplasty | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 43845 | Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 43846 | Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 43847 | Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 43848 | Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 43999 | Unlisted procedure, stomach | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 44132 | Donor Enterectomy, Open, W/Prep & Maintenance, Allograft; Cadaver Donor | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 44133 | Donor Enterectomy, Open With Prep & Maintenance, Allograft; Partial, Living Donor | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 44135 | Intestinal Allotransplantation; From Cadaver Donor | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 44136 | Intestinal Allotransplantation; From Living Donor | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 44715 | Backbench Standard Preparation Of Cadaver Or Living Donor Intestine Allograft | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 44720 | Backbench Reconstruction Of Cadaver Or Living Donor Intestine Allograft; Venous Anastomosis, Each | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 44721 | Backbench Reconstruction Of Cadaver Or Living Donor Intestine Allograft; Arterial Anastomosis, Each | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47133 | Donor hepatectomy (including cold preservation), from cadaver donor | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47135 | Liver Allotransplantation; Orthotopic, Partial/Whole, Cadaver/Living Donor, Any Age | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47140 | Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III) | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47141 | Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III and IV) | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47142 | Donor hepatectomy (including cold preservation), from living donor; total right lobectomy (segments V, VI, VII and VIII) | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47143 | Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft; Without Trisegment Or Lobe Split | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47144 | Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectom | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47145 | Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectom | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47146 | Backbench Reconstruction Of Cadaver Or Living Donor Liver Graft Prior To Allotransplantation; Venous Anastomosis, Each | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47147 | Backbench Reconstruction Of Cadaver Or Living Donor Liver Graft Prior To Allotransplantation; Arterial Anastomosis, Each | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47370 | Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47371 | Laparoscopy, surgical, ablation of 1 or more liver tumor(s); cryosurgical | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47380 | Ablation, open, of 1 or more liver tumor(s); radiofrequency | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47381 | Ablation, open, of 1 or more liver tumor(s); cryosurgical | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47382 | Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 47383 | Ablation, 1 or more liver tumor(s), percutaneous, cryoablation | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 48160 | Pancreatectomy, Total/Subtotal W/Autologous Transplantation Pancreas/Pancreatic Islets | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 48550 | Donor Pancreatectomy, W/Prep & Maintenance, Cadaver Donor, W/Wo Duodenal Segment | Standard Local Prior Authorization Code List, Pg 101 Original policy |
| 48551 | Backbench Standard Preparation Of Cadaver Donor Pancreas Allograft | Standard Local Prior Authorization Code List, Pg 102 Original policy |