Anthem Blue Cross Blue Shield of Georgia prior authorization, page 4
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 |
|---|---|---|
| 27403 | Arthrotomy with meniscus repair, knee | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27405 | Repair, primary, torn ligament and/or capsule, knee; collateral | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27407 | Repair, primary, torn ligament and/or capsule, knee; cruciate | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27409 | Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments | Standard Local Prior Authorization Code List, Pg 7 Original policy |
| 27412 | Autologous chondrocyte implantation, knee | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27415 | Osteochondral allograft, knee, open | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27416 | Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27425 | Lateral retinacular release, open | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27427 | Ligamentous reconstruction (augmentation), knee; extra-articular | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27428 | Ligamentous reconstruction (augmentation), knee; intra-articular (open) | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27429 | Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27437 | Arthroplasty, patella; without prosthesis | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27438 | Arthroplasty, patella; with prosthesis | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27440 | Arthroplasty, knee, tibial plateau | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27441 | Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27442 | Arthroplasty, femoral condyles or tibial plateau(s), knee | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27446 | Arthroplasty, knee, condyle and plateau; medial OR lateral compartment | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27447 | Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27486 | Revision of total knee arthroplasty, with or without allograft; 1 component | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27487 | Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27488 | Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27570 | Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices) | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27702 | Arthroplasty, ankle; with implant (total ankle) | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27703 | Arthroplasty, ankle; revision, total ankle | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27704 | Removal of ankle implant | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27860 | Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus) | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 27870 | Arthrodesis, ankle, open | Standard Local Prior Authorization Code List, Pg 8 Original policy |
| 28110 | Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure) | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28285 | Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy) | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28286 | Correction, cock-up fifth toe, with plastic skin closure (eg, Ruiz-Mora type procedure) | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28289 | Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28291 | Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint with implant | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28292 | Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28295 | Correction, hallux valgus (bunion), with or without sesamoidectomy;with proximal metatarsal osteotomy, any method | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28296 | Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal metatarsal osteotomy, any method | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28297 | Correction, hallux valgus (bunion), with or without sesamoidectomy; Lapidus-type procedure | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28298 | Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal phalanx osteotomy, any method | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28299 | Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with double osteotomy, any method | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28306 | Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28307 | Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal with autograft (other than first toe) | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28308 | Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28310 | Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure) | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28312 | Osteotomy, shortening, angular or rotational correction; other phalanges, any toe | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28315 | Sesamoidectomy, first toe (separate procedure) | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28446 | Open osteochondral autograft, talus (includes obtaining graft[s]) | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 28750 | Arthrodesis, great toe; metatarsophalangeal joint | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 29800 | Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 29804 | Arthroscopy, temporomandibular joint, surgical | Standard Local Prior Authorization Code List, Pg 9 Original policy |
| 29805 | Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29806 | Arthroscopy, shoulder, surgical; capsulorrhaphy | Standard Local Prior Authorization Code List, Pg 10 Original policy |