Anthem Blue Cross Blue Shield of Georgia prior authorization, page 54
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 |
|---|---|---|
| Q5140 | Injection, adalimumab-fkjp, biosimilar, 1 mg(cid:9) | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5141 | Injection, adalimumab-aaty, biosimilar, 1 mg(cid:9) | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5142 | Injection, adalimumab-ryvk biosimilar, 1 mg(cid:9) | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5143 | Injection, adalimumab-adbm, biosimilar, 1 mg(cid:9) | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5144 | Injection, adalimumab-aacf (Idacio), biosimilar, 1 mg(cid:9) | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q5145 | Injection, adalimumab-afzb (Abrilada), biosimilar, 1 mg(cid:9) | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q5147 | Injection, aflibercept-ayyh (Pavblu), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q5149 | Injection, aflibercept-abzv (Enzeevu), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q5150 | Injection, aflibercept-mrbb (Ahzantive), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q5151 | Injection, eculizumab-aagh (Epysqli), biosimilar, 2 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q5152 | Injection, eculizumab-aeeb (Bkemv), biosimilar, 2 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q5153 | Injection, aflibercept-yszy (opuviz), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q5154 | Injection, omalizumab-igec (Omlyclo), biosimilar, 5 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q5155 | Injection, aflibercept-jbvf (Yesafili), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q5164 | Injection, ustekinumab-hmny (starjemza), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q5168 | Injection, ranibizumab-leyk (nufymco), biosimilar, 0.1 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q5170 | Injection, aflibercept-boav (eydenzelt), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q9996 | Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q9997 | Injection, ustekinumab-ttwe (pyzchiva), intravenous, 1 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q9998 | Injection, ustekinumab-aekn (selarsdi), 1 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| Q9999 | Injection, ustekinumab-aauz (Otulfi), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| 11920 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| 11921 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| 11950 | Subcutaneous injection of filling material (eg, collagen); 1 cc or less | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| 11951 | Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| 11952 | Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| 11954 | Subcutaneous injection of filling material (eg, collagen); over 10.0 cc | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| 14040 | Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| 14041 | Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm | Standard Local Prior Authorization Code List, Pg 124 Original policy |
| 14060 | Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 14061 | Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15150 | Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15155 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15271 | Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15273 | Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15275 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15277 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15771 | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15773 | Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15775 | Punch graft for hair transplant; 1 to 15 punch grafts | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15776 | Punch graft for hair transplant; more than 15 punch grafts | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15780 | Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15781 | Dermabrasion; segmental, face | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15782 | Dermabrasion; regional, other than face | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15783 | Dermabrasion; superficial, any site (eg, tattoo removal) | Standard Local Prior Authorization Code List, Pg 125 Original policy |
| 15786 | Abrasion; single lesion (eg, keratosis, scar) | Standard Local Prior Authorization Code List, Pg 126 Original policy |
| 15788 | Chemical peel, facial; epidermal | Standard Local Prior Authorization Code List, Pg 126 Original policy |
| 15789 | Chemical peel, facial; dermal | Standard Local Prior Authorization Code List, Pg 126 Original policy |
| 15792 | Chemical peel, nonfacial; epidermal | Standard Local Prior Authorization Code List, Pg 126 Original policy |
| 15793 | Chemical peel, nonfacial; dermal | Standard Local Prior Authorization Code List, Pg 126 Original policy |