Anthem Blue Cross Blue Shield of Georgia prior authorization, page 5
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 |
|---|---|---|
| 29807 | Arthroscopy, shoulder, surgical; repair of SLAP lesion | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29819 | Arthroscopy, shoulder, surgical; with removal of loose body or foreign body | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29820 | Arthroscopy, shoulder, surgical; synovectomy, partial | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29821 | Arthroscopy, shoulder, surgical; synovectomy, complete | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29822 | Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29823 | Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29824 | Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29825 | Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29826 | Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29827 | Arthroscopy, shoulder, surgical; with rotator cuff repair | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29828 | Arthroscopy, shoulder, surgical; biceps tenodesis | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29860 | Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29861 | Arthroscopy, hip, surgical; with removal of loose body or foreign body | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29862 | Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum | Standard Local Prior Authorization Code List, Pg 10 Original policy |
| 29863 | Arthroscopy, hip, surgical; with synovectomy | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29866 | Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29867 | Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty) | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29868 | Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29870 | Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29871 | Arthroscopy, knee, surgical; for infection, lavage and drainage | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29873 | Arthroscopy, knee, surgical; with lateral release | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29874 | Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29875 | Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure) | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29876 | Arthroscopy, knee, surgical; synovectomy, major, 2 or more, Compartments (eg, medial or lateral) | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29877 | Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29879 | Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29880 | Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate, Compartment(s), when performed | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29881 | Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate, Compartment(s), when performed | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29882 | Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29883 | Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29884 | Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure) | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29885 | Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) | Standard Local Prior Authorization Code List, Pg 11 Original policy |
| 29886 | Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 29887 | Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 29888 | Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 29889 | Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 29892 | Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy) | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 29914 | Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 29915 | Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion) | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 29916 | Arthroscopy, hip, surgical; with labral repair | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 30115 | Excision, Nasal Polyp(S), Extensive | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 30130 | Excision inferior turbinate, partial or complete, any method | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 30140 | Submucous resection inferior turbinate, partial or complete, any method | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 30520 | Septoplasty/Submucous Resection W/Wo Cartilage Scoring/Contouring/Graft | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 30580 | Repair Fistula; Oromaxillary (Combine W/31030 If Antrotomy Is Included) | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 30620 | Septal or other intranasal dermatoplasty (does not include obtaining graft) | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 30801 | Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ab | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 30802 | Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ab | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 31032 | Sinusotomy, Maxillary (Antrotomy); Radical (Caldwell-Luc) W/Removal, Antrochoanal Polyps | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 31200 | Ethmoidectomy; Intranasal, Anterior | Standard Local Prior Authorization Code List, Pg 12 Original policy |