Anthem Blue Cross Blue Shield of Georgia prior authorization, page 45
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 |
|---|---|---|
| E0677 | Non-pneumatic sequential compression garment, trunk | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0678 | Non-pneumatic sequential compression garment, full leg | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0679 | Non-pneumatic sequential compression garment, half leg | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0680 | Non-pneumatic compression controller with sequential calibrated gradient pressure | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0681 | Non-pneumatic compression controller without calibrated gradient pressure | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0682 | Non-pneumatic sequential compression garment, full arm | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0683 | Non-pneumatic, non-sequential, peristaltic wave compression pump | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0734 | External upper limb tremor stimulator of the peripheral nerves of the wrist | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0738 | Upper extremity rehabilitation system providing active assistance to facilitate muscle re-education, includes microprocessor, all components and accessories | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0739 | Rehabilitation system with interactive interface providing active assistance in rehabilitation therapy, includes all components and accessories, motors, microprocessors, senso | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0745 | Neuromuscular stimulator, electronic shock unit | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0746 | Electromyography (EMG), biofeedback device | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0760 | Osteogenic stimulator, low intensity ultrasound, noninvasive | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0761 | Nonthermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0762 | Transcutaneous electrical joint stimulation device system, includes all accessories | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0764 | Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0765 | FDA-approved nerve stimulator, for treatment of nausea and vomiting | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0769 | Electrical stimulation or electromagnetic wound treatment device, not otherwise classified | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0770 | Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified | Standard Local Prior Authorization Code List, Pg 113 Original policy |
| E0782 | Non-Programble Infusion Pump | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E0783 | Programmable Infusion Pump | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E0786 | Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter) | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E0986 | Manual wheelchair accessory, push-rim activated power assist, each | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E1002 | Wheelchair accessory, power seating system, tilt only | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E1006 | Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E1007 | Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E1009 | Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system, including pushrod and legrest, each | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E1010 | Wheelchair accessory, addition to power seating system, power leg elevation system, including legrest, pair | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E1012 | Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E1230 | Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E1801 | Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E1806 | Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E1811 | Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E1816 | Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E1841 | Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E2298 | Complex rehabilitative power wheelchair accessory, power seat elevation system, any type | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| E3200 | Gait modulation system, rhythmic auditory stimulation, including restricted therapy software, all components and accessories, prescription only | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| G0341 | Percutaneous islet celltrans | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| G0342 | Laparoscopy islet cell trans | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| G0343 | Laparotomy islet cell transp | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| G0460 | Autologous platelet rich plasma (PRP) or other blood-derived product for nondiabetic chronic wounds/ulcers (includes, as applicable: administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment) | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| G0465 | Autologous platelet rich plasma (PRP) or other blood-derived product for diabetic chronic wounds/ulcers, using an FDA-cleared device for this indication, (includes, as applicable: administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment) | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| H0004 | Behavioral health counseling and therapy, per 15 minutes | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| H0006 | Alcohol and/or drug services; case management | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| H0015 | Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| H0017 | Behavioral health; residential (hospital residential treatment program), without room and board, per diem | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| H0019 | Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, pe | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| H0023 | Behavioral health outreach service (planned approach to reach a targeted population) | Standard Local Prior Authorization Code List, Pg 114 Original policy |
| H0031 | Mental health assessment, by nonphysician | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| H0032 | Mental health service plan development by nonphysician | Standard Local Prior Authorization Code List, Pg 115 Original policy |