Anthem Blue Cross Blue Shield of Georgia prior authorization, page 41
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 |
|---|---|---|
| 58275 | Vaginal hysterectomy, with total or partial vaginectomy | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58280 | Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58285 | Vaginal hysterectomy, radical (Schauta type operation) | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58548 | Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58552 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58554 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58570 | Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58571 | Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less;with removal of tube(s) and/or ovary (s) | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58572 | Laparoscopy; surgical, with total hysterectomy, for uterus greater than 250 g | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58573 | Laparoscopy; surgical, with total hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary (s) | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58953 | Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58954 | Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58956 | Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy | Standard Local Prior Authorization Code List, Pg 104 Original policy |
| 58999 | Unlisted procedure, female genital system (nonobstetrical) | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 61630 | Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 61635 | Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 61736 | Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 simple lesion | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 61737 | Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; multiple trajectories for multiple or complex lesions | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 61850 | Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 61860 | Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 61863 | Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 61867 | Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 61886 | Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 61889 | Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, when performed, with direct or inductive coupling, with connection to depth and/or cortical strip electrode array(s) | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 61891 | Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode array(s) | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 64505 | Injection, anesthetic agent; sphenopalatine ganglion | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 64736 | Transection or avulsion of; mental nerve | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 64738 | Transection or avulsion of; inferior alveolar nerve by osteotomy | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 64740 | Transection or avulsion of; lingual nerve | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 64742 | Transection or avulsion of; facial nerve, differential or complete | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 64864 | Suture of facial nerve; extracranial | Standard Local Prior Authorization Code List, Pg 105 Original policy |
| 64865 | Suture of facial nerve; infratemporal, with or without grafting | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 64866 | Anastomosis; facial-spinal accessory | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 64868 | Anastomosis; facial-hypoglossal | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 64999 | Unlisted procedure, nervous system | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 69090 | Ear piercing | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 69300 | Otoplasty, protruding ear, with or without size reduction | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 69949 | Unlisted procedure, inner ear | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 69955 | Total facial nerve decompression and/or repair (may include graft) | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 76376 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under co | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 76377 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under co | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 81490 | Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 81517 | Liver disease, analysis of 3 biomarkers (hyaluronic acid [HA], procollagen III amino terminal peptide [PIIINP], tissue inhibitor of metalloproteinase 1 [TIMP-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 81535 | Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 81538 | Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 81560 | Transplantation medicine (allograft rejection, pediatric liver and small bowel), measurement of donor and third-party-induced CD154+T-cytotoxic memory cells, utilizing whole peripheral blood, algorithm reported as a rejection risk score | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 81596 | Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays (ALT, A2- macroglobulin, apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utilizing serum, prognostic algorithm reported as scores for fibrosis and necroinflammatory activity in liver | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 82233 | Beta-amyloid; 1-40 | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 82234 | Beta-amyloid; 1-42 | Standard Local Prior Authorization Code List, Pg 106 Original policy |
| 82542 | Column Chromatography/Mass Spectrometry; Quantitative, Single Stationary & Mobile Phase | Standard Local Prior Authorization Code List, Pg 106 Original policy |