Anthem Blue Cross Blue Shield of Georgia prior authorization, page 46
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 |
|---|---|---|
| H0035 | Mental health partial hospitalization, treatment, less than 24 hours | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| H0036 | Community psychiatric supportive treatment, face- to-face, per 15 minutes | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| H0038 | Self-help/peer services, per 15 minutes | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| H0039 | Assertive community treatment, face-to-face, per 15 minutes | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| H0040 | Assertive community treatment program, per diem | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| H0046 | Mental health services, not otherwise specified | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| H2012 | Behavioral health day treatment, per hour | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| H2014 | Skills training and development, per 15 minutes | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| H2015 | Comprehensive community support services, per 15 minutes | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| H2019 | Therapeutic behavioral services, per 15 minutes | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| H2020 | Therapeutic behavioral services, per diem | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| H2021 | Community-based wrap-around services, per 15 minutes | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J1411 | Injection, etranacogene dezaparvovec-drlb, per therapeutic dose | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J1412 | Injection, valoctocogene roxaparvovec-rvox, per ml, containing nominal 2 x 10^13 vector genomes | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J1413 | Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J1414 | Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J3391 | Injection, atidarsagene autotemcel, per treatment | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J3392 | Injection, exagamglogene autotemcel, per treatment | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J3393 | Injection, betibeglogene autotemcel, per treatment (Zynteglo) | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J3394 | Injection, lovotibeglogene autotemcel, per treatment [Lyfgenia] | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J3398 | Injection, voretigene neparvovec-rzyl, 1 billion vector genomes | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J3399 | Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector genomes | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J3402 | Injection, remestemcel-l-rknd, per therapeutic dose | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J3403 | Revakinagene taroretcel-lwey, per implant | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J8499 | Prescription drug, oral, nonchemotherapeutic, NOS | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| J9248 | Injection, melphalan (Hepzato), 1 mg | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0010 | Standard-weight frame motorized/power wheelchair | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0011 | Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0012 | Lightweight portable motorized/power wheelchair | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0013 | Custom motorized/power wheelchair base | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0800 | Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0801 | Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0802 | Power operated vehicle, group 1 very heavy-duty, patient weight capacity 451 to 600 pounds | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0806 | Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0807 | Power operated vehicle, group 2 heavy-duty, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0808 | Power operated vehicle, group 2 very heavy-duty, patient weight capacity 451 to 600 pounds | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0813 | Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0814 | Power wheelchair, group 1 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0815 | Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 115 Original policy |
| K0816 | Power wheelchair, group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0820 | Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0821 | Power wheelchair, group 2 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0822 | Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0823 | Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0824 | Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0825 | Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0826 | Power wheelchair, group 2 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0827 | Power wheelchair, group 2 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0828 | Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0829 | Power wheelchair, group 2 extra heavy-duty, captain's chair, patient weight 601 pounds or more | Standard Local Prior Authorization Code List, Pg 116 Original policy |