Anthem Blue Cross Blue Shield of Georgia prior authorization, page 42
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 |
|---|---|---|
| 82787 | Gammaglobulin (immunoglobulin); immunoglobulin subclasses (eg, IgG1, 2, 3, or 4), each | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 83516 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitativ | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 83520 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise sp | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 83884 | Neurofilament light chain | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 83921 | Organic Acid, Single, Quantitative | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 84393 | Tau, phosphorylated | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 84394 | Tau, total | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 86001 | Allergen specific IgG quantitative or semiquantitative, each allergen | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 86343 | Leukocyte histamine release test (LHR) [includes basophil histamine release test] | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 86352 | Cellular function assay involving stimulation (eg, mitogen or antigen) and detection of biomarker (eg, ATP) | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 88356 | Morphometric Analysis; Nerve | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 90867 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 90868 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 90869 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 90875 | Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 90876 | Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 45 minutes | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 93799 | Unlisted cardiovascular service or procedure | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 93998 | Unlisted noninvasive vascular diagnostic study | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 97039 | Unlisted modality (specify type and time if constant attendance) | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 97151 | Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face- to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 97152 | Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 97153 | Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 97154 | Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 97155 | Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to- face with one patient, each 15 minutes | Standard Local Prior Authorization Code List, Pg 107 Original policy |
| 97156 | Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 97157 | Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 97158 | Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 97610 | Low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 99199 | Unlisted special service, procedure or report | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 0002M | Liver disease, ten biochemical assays (ALT, A2- macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and alcoholic steatohepatitis (ASH) | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 0003M | Liver disease, ten biochemical assays (ALT, A2- macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and nonalcoholic steatohepatitis (NASH) | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 0080U | Oncology (lung), mass spectrometric analysis of galectin-3-binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk factors (age, smoking status, nodule diameter, nodule-spiculation status and nodule location), utilizing plasma, algorithm reported as a categorical probability of malignancy | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 0088U | Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizing transplant biopsy tissue, algorithm reported as a probability score for rejection | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 0100T | Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 0105U | Nephrology (chronic kidney disease), multiplex electrochemiluminescent immunoassay (ECLIA) of tumor necrosis factor receptor 1A, receptor superfamily 2 (TNFR1, TNFR2), and kidney injury molecule-1 (KIM-1) combined with longitudinal clinical data, including APOL1 genotype if available, and plasma (isolated fresh or frozen), algorithm reported as probability score for rapid kidney function decline (RKFD) | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 0108U | Gastroenterology (Barrett's esophagus), whole slide-digital imaging, including morphometric analysis, computer-assisted quantitative immunolableing of 9 protein biomarkers (p1 | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 0117U | Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5- hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid (3- HPMA), quinolinic acid, kynurenic acid), LC- MS/MS, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 0164U | Gastroenterology (irritable bowel syndrome [IBS]), immunoassay for anti-CdtB and anti-vinculin antibodies, utilizing plasma, algorithm for elevated or not elevated qualitative results | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 0166U | Liver disease, 10 biochemical assays (a2- macroglobulin, haptoglobin, apolipoprotein A1, bilirubin, GGT, ALT, AST, triglycerides, cholesterol, fasting glucose) and biometric and demographic data, utilizing serum, algorithm reported as scores for fibrosis, necroinflammatory activity, and steatosis with a summary interpretation | Standard Local Prior Authorization Code List, Pg 108 Original policy |
| 0202T | Posterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0232T | Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0247U | Obstetrics (preterm birth), insulin-like growth factor-binding protein 4 (IBP4), sex hormone-binding globulin (SHBG), quantitative measurement by LC-MS/MS, utilizing maternal serum, combined with clinical data, reported as predictive-risk stratification for spontaneous preterm birth | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0248U | Oncology (brain), spheroid cell culture in a 3D microenvironment, 12 drug panel, tumor-response prediction for each drug | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0263T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete pro | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0264T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete pro | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0265T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral o | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0312U | Autoimmune diseases (eg, systemic lupus erythematosus [SLE]), analysis of 8 IgG autoantibodies and 2 cell-bound complement activation products using enzyme-linked immunosorbent immunoassay (ELISA), flow cytometry and indirect immunofluorescence, serum, or plasma and whole blood, individual components reported along with an algorithmic SLE- likelihood assessment | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0344U | Hepatology (nonalcoholic fatty liver disease [NAFLD]), semiquantitative evaluation of 28 lipid markers by liquid chromatography with tandem mass spectrometry (LC-MS/MS), serum, reported as at-risk for nonalcoholic steatohepatitis (NASH) or not NASH | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0345T | Transcatheter mitral valve repair percutaneous approach via the coronary sinus | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0358U | Neurology (mild cognitive impairment), analysis of β- amyloid 1-42 and 1-40, chemiluminescence enzyme immunoassay, cerebral spinal fluid, reported as positive, likely positive, or negative | Standard Local Prior Authorization Code List, Pg 109 Original policy |