Anthem Blue Cross Blue Shield of Georgia prior authorization, page 44
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 |
|---|---|---|
| 0933T | Transcatheter implantation of wireless left atrial pressure sensor for long-term left atrial pressure monitoring, including sensor calibration and deployment, right heart cath | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A0430 | Fixed Wing Air Transport | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A0431 | Rotary Wing Air Transport | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A0435 | Fixed Wing Air Mileage | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A0436 | Rotary Wing Air Mileage | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A0888 | Noncovered Ambulance Mileage | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A2022 | InnovaBurn or InnovaMatrix XL, per sq cm | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A2023 | InnovaMatrix PD, 1 mg | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A2024 | Resolve Matrix, per sq cm | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A2026 | Restrata MiniMatrix, 5 mg | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A2027 | Matriderm, per square centimeter | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A2028 | Micromatrix flex, per mg | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A2029 | Mirotract wound matrix sheet, per cubic centimeter | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A4438 | Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A4468 | Exsufflation belt, includes all supplies and accessories | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A4542 | Supplies and accessories for external upper limb tremor stimulator of the peripheral nerves of the wrist | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A4596 | Cranial electrotherapy stimulation (ces) system supplies and accessories, per month | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A4600 | Sleeve for intermittent limb compression device, replacement only, each | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A9268 | Programmer for transient, orally ingested capsule | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| A9269 | Programmable, transient, orally ingested capsule, for use with external programmer, per month | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| B9999 | NOC for parenteral supplies | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| C1734 | Orthopedic/device/drug matrix for opposing bone-to- bone or soft tissue-to bone (implantable) | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| C1789 | Prosthesis, breast (implantable) | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| C2614 | Probe, percutaneous lumbar discectomy | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| C8003 | Implantation of medial knee extraarticular implantable shock absorber spanning the knee joint from distal femur to proximal tibia, open, includes measurements, positioning and | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| C9762 | Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| C9763 | Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| C9785 | Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| C9796 | Repair of enterocutaneous fistula small intestine or colon (excluding anorectal fistula) with plug (e.g., porcine small intestine submucosa [SIS]) | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| C9808 | Nerve cryoablation probe (e.g., cryoice, cryosphere, cryosphere max, cryoice cryosphere, cryoice cryo2), including probe and all disposable system components, non-opioid medic | Standard Local Prior Authorization Code List, Pg 112 Original policy |
| C9809 | Cryoablation needle (e.g., iovera system), including needle/tip and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medic | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0481 | Intrapulmonary percussive ventilation system and related accessories | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0650 | Pneumatic compressor, nonsegmental home model | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0651 | Pneumatic compressor, segmental home model without calibrated gradient pressure | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0652 | Pneumatic compressor, segmental home model with calibrated gradient pressure | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0655 | Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0656 | Segmental pneumatic appliance for use with pneumatic compressor, trunk | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0657 | Segmental pneumatic appliance for use with pneumatic compressor, chest | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0658 | Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full arms and chest | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0660 | Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0665 | Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0666 | Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0667 | Segmental pneumatic appliance for use with pneumatic compressor, full leg | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0668 | Segmental pneumatic appliance for use with pneumatic compressor, full arm | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0669 | Segmental pneumatic appliance for use with pneumatic compressor, half leg | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0670 | Segmental pneumatic appliance for use with pneumatic compressor, integrated, two full legs and trunk | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0671 | Segmental gradient pressure pneumatic appliance, full leg | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0672 | Segmental gradient pressure pneumatic appliance, full arm | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0673 | Segmental gradient pressure pneumatic appliance, half leg | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0676 | Intermittent limb compression device (includes all accessories), not otherwise specified | Standard Local Prior Authorization Code List, Pg 113 Original policy |