Anthem Blue Cross Blue Shield of Georgia prior authorization, page 55
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 |
|---|---|---|
| 15820 | Blepharoplasty, lower eyelid | Standard Local Prior Authorization Code List, Pg 126 Original policy |
| 15821 | Blepharoplasty, lower eyelid; with extensive herniated fat pad | Standard Local Prior Authorization Code List, Pg 126 Original policy |
| 15822 | Blepharoplasty, upper eyelid | Standard Local Prior Authorization Code List, Pg 126 Original policy |
| 15823 | Blepharoplasty, upper eyelid; with excessive skin weighting down lid | Standard Local Prior Authorization Code List, Pg 126 Original policy |
| 15824 | Rhytidectomy; forehead | Standard Local Prior Authorization Code List, Pg 126 Original policy |
| 15826 | Rhytidectomy; glabellar frown lines | Standard Local Prior Authorization Code List, Pg 126 Original policy |
| 15830 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy | Standard Local Prior Authorization Code List, Pg 126 Original policy |
| 15877 | Suction assisted lipectomy; trunk | Standard Local Prior Authorization Code List, Pg 126 Original policy |
| 17106 | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm | Standard Local Prior Authorization Code List, Pg 126 Original policy |
| 17107 | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 17108 | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 17380 | Electrolysis epilation, each 30 minutes | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 19300 | Mastectomy for gynecomastia | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 19318 | Breast reduction | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 20979 | Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 21120 | Genioplasty; augmentation (autograft, allograft, prosthetic material) | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 21121 | Genioplasty; sliding osteotomy, single piece | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 21122 | Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 21123 | Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 21125 | Augmentation, mandibular body or angle; prosthetic material | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 21127 | Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 21141 | Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 21142 | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 21143 | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft | Standard Local Prior Authorization Code List, Pg 127 Original policy |
| 21150 | Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21193 | Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21194 | Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21195 | Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21196 | Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21198 | Osteotomy, mandible, segmental | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21199 | Osteotomy, mandible, segmental; with genioglossus advancement | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21206 | Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21208 | Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21209 | Osteoplasty, facial bones; reduction | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21210 | Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21215 | Graft, bone; mandible (includes obtaining graft) | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21244 | Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21245 | Reconstruction of mandible or maxilla, subperiosteal implant; partial | Standard Local Prior Authorization Code List, Pg 128 Original policy |
| 21246 | Reconstruction of mandible or maxilla, subperiosteal implant; complete | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 21685 | Hyoid myotomy and suspension | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 22526 | Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 22586 | Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 22867 | Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 22869 | Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 28890 | Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 30117 | Excision or destruction (eg, laser), intranasal lesion; internal approach | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 30468 | Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s) | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 30469 | Repair of nasal valve collapse with low energy, temperature-controlled (ie, radiofrequency) subcutaneous/submucosal remodeling | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 31242 | Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation, posterior nasal nerve | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 31243 | Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve | Standard Local Prior Authorization Code List, Pg 129 Original policy |