Anthem Blue Cross Blue Shield of Georgia prior authorization, page 47
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 |
|---|---|---|
| K0830 | Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0831 | Power wheelchair, group 2 standard, seat elevator, captain's chair, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0835 | Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0836 | Power wheelchair, group 2 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0837 | Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0838 | Power wheelchair, group 2 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0839 | Power wheelchair, group 2 very heavy-duty, single power option sling/solid seat/back, patient weight capacity 451 to 600 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0840 | Power wheelchair, group 2 extra heavy-duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0841 | Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0842 | Power wheelchair, group 2 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0843 | Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0848 | Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0849 | Power wheelchair, group 3 standard, captain's chair, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0850 | Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0851 | Power wheelchair, group 3 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0852 | Power wheelchair, group 3 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0853 | Power wheelchair, group 3 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0854 | Power wheelchair, group 3 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more | Standard Local Prior Authorization Code List, Pg 116 Original policy |
| K0855 | Power wheelchair, group 3 extra heavy-duty, captain's chair, patient weight capacity 601 pounds or more | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0856 | Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0857 | Power wheelchair, group 3 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0858 | Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0859 | Power wheelchair, group 3 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0860 | Power wheelchair, group 3 very heavy-duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0861 | Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0862 | Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0863 | Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0864 | Power wheelchair, group 3 extra heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0868 | Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0869 | Power wheelchair, group 4 standard, captain's chair, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0870 | Power wheelchair, group 4 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0871 | Power wheelchair, group 4 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0877 | Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0878 | Power wheelchair, group 4 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0879 | Power wheelchair, group 4 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0880 | Power wheelchair, group 4 very heavy-duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0884 | Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0885 | Power wheelchair, group 4 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0886 | Power wheelchair, group 4 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0890 | Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0891 | Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| K0900 | Customized durable medical equipment, other than wheelchair | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| L1499 | Spinal orthosis, not otherwise specified | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| L2999 | Lower extremity orthoses, not otherwise specified | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| L8045 | Auricular prosthesis, provided by a nonphysician | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| L8600 | Implantable breast prosthesis, silicone or equal | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| L8702 | Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessorie | Standard Local Prior Authorization Code List, Pg 117 Original policy |
| Q2041 | Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q2042 | Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q2053 | Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Standard Local Prior Authorization Code List, Pg 118 Original policy |