Anthem Blue Cross Blue Shield of Georgia prior authorization, page 49
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 |
|---|---|---|
| S2061 | Donor lobectomy (lung) for transplantation, living donor | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| S2065 | Simultaneous pancreas kidney transplantation | Standard Local Prior Authorization Code List, Pg 118 Original policy |
| S2066 | Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S2067 | Breast reconstruction of a single breast with “stacked” deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S2068 | Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S2102 | Islet Cell Tissue Transplant | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S2103 | Adrenal Tissue Transplant | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S2140 | Cord blood harvesting for transplantation, allogeneic | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S2142 | Cord Blood-Derived Stem-Cell | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S2150 | Bone marrow or blood-derived peripheral stem cell harvesting and transplantation, allogenic or autologous, including phe | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S5108 | Home care training to home care client, per 15 minutes | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S9002 | Intravaginal motion sensor system, provides biofeedback for pelvic floor muscle rehabilitation device | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S9123 | Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used) | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S9124 | Nursing care, in the home; by licensed practical nurse, per hour | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S9128 | Speech Therapy, In The Home | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S9480 | Intensive Outpatient Psychia | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S9960 | Ambulance service, conventional air services, nonemergency transport, one way (fixed wing) | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| S9961 | Ambulance service, conventional air service, nonemergency transport, one way (rotary wing) | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| T1000 | Private duty/independent nursing service(s) - licensed, up to 15 minutes | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| T1002 | RN services, up to 15 minutes | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| T1003 | LPN/LVN services, up to 15 minutes | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| T1030 | Nursing care, in the home, by registered nurse, per diem | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| T1031 | Nursing care, in the home, by licensed practical nurse, per diem | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| T2036 | Therapeutic camping, overnight, waiver; each session | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| T2037 | Therapeutic camping, day, waiver; each session | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| 90281 | Immune globulin (Ig), human, for intramuscular use | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| 90283 | Immune globulin (IgIV), human, for intravenous use | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| 90284 | Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| 90378 | Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| 90380 | Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| 90381 | Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| 90382 | Respiratory syncytial virus, monoclonal antibody, seasonal dose, 0.7 mL, for intramuscular use | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| C9047 | Injection, caplacizumab-yhdp, 1 mg | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| C9257 | Injection, bevacizumab, 0.25 mg | Standard Local Prior Authorization Code List, Pg 119 Original policy |
| C9399 | Unclassified Drugs Or Biologicals | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| G2082 | Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self administration, includes 2 hours post administration observation | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| G2083 | Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg esketamine nasal self administration, includes 2 hours post administration observation | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0013 | Esketamine, nasal spray, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0129 | Injection, abatacept, 10 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0139 | Injection, adalimumab, 1 mg(cid:9) | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0174 | Injection, lecanemab-irmb, 1mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0175 | Injection, donanemab-azbt, 2 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0177 | Injection, aflibercept HD, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0178 | Injection, aflibercept, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0179 | Injection, brolucizumab-dbll, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0180 | Injection, agalsidase beta, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0202 | Injection, alemtuzumab, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0217 | Injection, velmanase alfa-tycv, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0218 | Injection, olipudase alfa-rpcp, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0219 | Injection, avalglucosidase alfa-ngpt, 4 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |