Anthem Blue Cross Blue Shield of Georgia prior authorization, page 40
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 |
|---|---|---|
| 48552 | Backbench Reconstruction Of Cadaver Donor Pancreas Allograft Prior To Transplantation, Venous Anastomosis, Each | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 48554 | Transplantation, Pancreatic Allograft | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 48556 | Removal, Transplanted Pancreatic Allograft | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 48999 | Unlisted procedure, pancreas | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 50250 | Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 50300 | Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 50320 | Donor nephrectomy (including cold preservation); open, from living donor | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 50323 | Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 50325 | Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 50327 | Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 50328 | Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 50329 | Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, each | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 50340 | Recipient nephrectomy (separate procedure) | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 50360 | Renal allotransplantation, implantation of graft; without recipient nephrectomy | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 50365 | Renal allotransplantation, implantation of graft; with recipient nephrectomy | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 50547 | Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 52441 | Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 52648 | Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed) | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 52649 | Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed) | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 53448 | Remov & Replace Inflatable Sphincter W/Pump/Reservoir/Cuff, Infected, W/Irrig & Debride | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 53854 | Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 53899 | Unlisted procedure, urinary system | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 54125 | Amputation of penis; complete | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 54440 | Plastic operation of penis for injury | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 54520 | Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach | Standard Local Prior Authorization Code List, Pg 102 Original policy |
| 54660 | Insertion of testicular prosthesis (separate procedure) | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 54690 | Laparoscopy, surgical; orchiectomy | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 55180 | Scrotoplasty; complicated | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 55899 | Unlisted procedure, male genital system | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 56625 | Vulvectomy simple; complete | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 56800 | Plastic repair of introitus | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 56805 | Clitoroplasty for intersex state | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 57110 | Vaginectomy, complete removal of vaginal wall | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 57265 | Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed; with enterocele repair | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 57270 | Repair of enterocele, abdominal approach (separate procedure) | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 57280 | Colpopexy, abdominal approach | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 57284 | Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 57285 | Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 57291 | Construction of artificial vagina; without graft | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 57292 | Construction of artificial vagina; with graft | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 57296 | Revision (including removal) of prosthetic vaginal graft; open abdominal approach | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 57335 | Vaginoplasty for intersex state | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 57423 | Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 58150 | Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 58152 | Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (eg, Marshall-Marchetti-Krantz, Burch) | Standard Local Prior Authorization Code List, Pg 103 Original policy |
| 58180 | Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58200 | Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s) | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58210 | Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s) | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58240 | Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58267 | Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra typ | Standard Local Prior Authorization Code List, Pg 104 Original policy |