Anthem Blue Cross Blue Shield of Georgia prior authorization, page 48
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 |
|---|---|---|
| Q2054 | Lisocabtagene maraleucel, up to 110 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 |
| Q2055 | Idecabtagene vicleucel, up to 460 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q2056 | Ciltacabtagene autoleucel, up to 100 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q2057 | Afamitresgene autoleucel, including leukapheresis and dose preparation procedures, per therapeutic dose | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q2058 | Obecabtagene autoleucel, 10 up to 400 million cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per infusion | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4285 | NuDYN DL or NuDYN DL MESH, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4286 | NuDYN SL or NuDYN SLW, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4305 | American Amnion AC Tri-Layer, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4306 | American Amnion AC, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4307 | American Amnion, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4308 | Sanopellis, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4309 | VIA Matrix, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4311 | Acesso, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4312 | Acesso AC, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4313 | DermaBind FM, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4314 | Reeva FT, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4315 | RegeneLink Amniotic Membrane Allograft, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4316 | AmchoPlast, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4317 | VitoGraft, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4318 | E-Graft, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4319 | SanoGraft, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4320 | PelloGraft, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4321 | RenoGraft, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4322 | CaregraFT, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4323 | alloPLY, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4324 | AmnioTX, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4325 | ACApatch, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4326 | WoundPlus, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4327 | DuoAmnion, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4328 | MOST, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4329 | Singlay, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4330 | TOTAL, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4331 | Axolotl Graft, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4332 | Axolotl DualGraft, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4333 | ArdeoGraft, per sq cm | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4336 | Artacent c, per square centimeter | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4337 | Artacent trident, per square centimeter | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4338 | Artacent velos, per square centimeter | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4339 | Artacent vericlen, per square centimeter | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4340 | Simpligraft, per square centimeter | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4341 | Simplimax, per square centimeter | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4342 | Theramend, per square centimeter | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4343 | Dermacyte ac matrix amniotic membrane allograft, per square centimeter | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4344 | Tri-membrane wrap, per square centimeter | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| Q4345 | Matrix hd allograft dermis, per square centimeter | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| S0201 | Partial Hospitalization Services, Less Than 24 Hours, Per Diem | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| S2053 | Transplantation of small intestine and liver allografts | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| S2054 | Transplantation of multivisceral organs | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| S2055 | Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| S2060 | Lobar lung transplantation | Standard Local Prior Authorization Code List, Pg 118 Original policy |