Anthem Blue Cross Blue Shield of Georgia prior authorization, page 43
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 |
|---|---|---|
| 0360U | Oncology (lung), enzyme-linked immunosorbent assay (ELISA) of 7 autoantibodies (p53, NY-ESO-1, CAGE, GBU4-5, SOX2, MAGE A4, and HuD), plasma, algorithm reported as a categorical result for risk of malignancy | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0362T | Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior. | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0373T | Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior. | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0376U | Oncology (prostate cancer), image analysis of at least 128 histologic features and clinical factors, prognostic algorithm determining the risk of distant metastases, and prost | Standard Local Prior Authorization Code List, Pg 109 Original policy |
| 0407U | Nephrology (diabetic chronic kidney disease [CKD]), multiplex electrochemiluminescent immunoassay (ECLIA) of soluble tumor necrosis factor receptor 1 (sTNFR1), soluble tumor necrosis receptor 2 (sTNFR2), and kidney injury molecule 1 (KIM-1) combined with clinical data, plasma, algorithm reported as risk for progressive decline in kidney function | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0412U | Beta amyloid, AB42/40 ratio, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and qualitative ApoE isoform-specific proteotyping, plasma combined with age, algorithm reported as presence or absence of brain amyloid pathology | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0435U | Oncology, chemotherapeutic drug cytotoxicity assay of cancer stem cells (CSCs), from cultured CSCs and primary tumor cells, categorical drug response reported based on cytotox | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0440T | Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0441T | Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0442T | Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve) | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0457U | Perfluoroalkyl substances (PFAS) (eg, perfluorooctanoic acid, perfluorooctane sulfonic acid), 9 PFAS compounds by LC-MS/MS, plasma or serum, quantitative | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0459U | B-amyloid (Abeta42) and total tau (tTau), electrochemiluminescent immunoassay (ECLIA), cerebral spinal fluid, ratio reported as positive or negative for amyloid pathology | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0472T | Device evaluation, interrogation, and initial programming of intra-ocular retinal electrode array (eg, retinal prosthesis), in person, with iterative adjustment of the implantable device to test functionality, select optimal permanent programmed values with analysis, including visual training, with review and report by a qualified health care professional | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0473T | Device evaluation and interrogation of intra-ocular retinal electrode array (eg, retinal prosthesis), in person, including reprogramming and visual training, when performed, with review and report by a qualified health care professional | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0480U | Infectious disease (bacteria, viruses, fungi, and parasites), cerebrospinal fluid (CSF), metagenomic next-generation sequencing (DNA and RNA), bioinformatic analysis, with pos | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0481T | Injection(s), autologous white blood cell concentrate (autologous protein solution), any site, including image guidance, harvesting and preparation, when performed | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0482U | Obstetrics (preeclampsia), biochemical assay of soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF), serum, ratio reported for sFlt-1/PlGF, with ris | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0483T | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0484T | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (eg, thoracotomy, transapical) | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0494T | Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system, including decannulation, separation from the perfusion system, and cold preservation of the allograft prior to implantation, when performed | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0495T | Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (eg, pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; first two hours in sterile field | Standard Local Prior Authorization Code List, Pg 110 Original policy |
| 0503U | Neurology (Alzheimer disease), beta amyloid (AB40, AB42, AB42/40 ratio) and tau-protein (ptau217, np-tau217, ptau217/np-tau217 ratio), blood, immunoprecipitation with quantita | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0521U | Rheumatoid factor IgA and IgM, cyclic citrullinated peptide (CCP) antibodies, and scavenger receptor A (SR-A) by immunoassay, blood | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0524U | Obstetrics (preeclampsia), sFlt1/PlGF ratio, immunoassay, utilizing serum or plasma, reported as a value | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0544T | Transcatheter mitral valve annulus reconstruction, with implantation of adjustable annulus reconstruction device, percutaneous approach including transseptal puncture | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0545T | Transcatheter tricuspid valve annulus reconstruction with implantation of adjustable annulus reconstruction device, percutaneous approach | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0569T | Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0584T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; percutaneous | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0585T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; laparoscopic | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0586T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; open | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0646T | Transcatheter tricuspid valve implantation/replacement (TTVI) with pro | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0659T | Transcatheter intracoronary infusion of supersaturated oxygen in conjunction with percutaneous coronary revascularization during acute myocardial infarction, including catheter placement, imaging guidance (eg, fluoroscopy), angiography, and radiologic supervision and interpretation | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0664T | Donor hysterectomy (including cold preservation); open, from cadaver donor | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0665T | Donor hysterectomy (including cold preservation); open, from living donor | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0666T | Donor hysterectomy (including cold preservation); laparoscopic or robotic, from living donor | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0667T | Recipient uterus allograft transplantation from cadaver or living donor | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0668T | Backbench standard preparation of cadaver or living donor uterine allograft prior to transplantation, including dissection and removal of surrounding soft tissues and preparation of uterine vein(s) and uterine artery(ies), as necessary | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0669T | Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; venous anastomosis, each | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0670T | Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; arterial anastomosis, each | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0686T | Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0692T | Therapeutic ultrafiltration | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0714T | Transperineal laser ablation of benign prostatic hyperplasia, including imaging guidance | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0748T | Injections of stem cell product into perianal perifistular soft tissue, including fistula preparation (eg, removal of setons, fistula curettage, closure of internal openings) | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0810T | Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0813T | Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of intragastric bariatric balloon | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0888T | Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including imaging guidance | Standard Local Prior Authorization Code List, Pg 111 Original policy |
| 0894T | Cannulation of the liver allograft in preparation for connection to the normothermic perfusion device and decannulation of the liver allograft following normothermic perfusion | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| 0895T | Connection of liver allograft to normothermic machine perfusion device, hemostasis control; initial 4 hours of monitoring time, including hourly physiological and laboratory assessments (eg, perfusate temperature, perfusate pH, hemodynamic parameters, bile production, bile pH, bile glucose, biliary bicarbonate, lactate levels, macroscopic assessment) | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| 0915T | Insertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and ther | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| 0923T | Removal and replacement of permanent cardiac contractility modulationdefibrillation pulse generator only | Standard Local Prior Authorization Code List, Pg 112 Original policy |