Anthem Blue Cross Blue Shield of Georgia prior authorization, page 56
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 |
|---|---|---|
| 31660 | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 31661 | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 33208 | Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 33214 | Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator) | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 33216 | Insertion of a single transvenous electrode, permanent pacemaker or cardioverter-defibrillator | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 33217 | Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverter-defibrillator | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 33224 | Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existin | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 33226 | Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of existing generator) | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 33228 | Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system | Standard Local Prior Authorization Code List, Pg 129 Original policy |
| 33229 | Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 33230 | Insertion of implantable defibrillator pulse generator only; with existing dual leads | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 33231 | Insertion of implantable defibrillator pulse generator only; with existing multiple leads | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 33240 | Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 33249 | Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 33263 | Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead system | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 33264 | Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 33270 | Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 33271 | Insertion of subcutaneous implantable defibrillator electrode | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 33274 | Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, fe | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 33275 | Transcatheter removal of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 33289 | Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 36511 | Therapeutic apheresis; for white blood cells | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 36512 | Therapeutic apheresis; for red blood cells | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 36513 | Therapeutic apheresis; for platelets | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 36514 | Therapeutic apheresis; for plasma pheresis | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 36516 | Therapeutic apheresis; with extracorporeal immunoadsorption, selective adsorption or selective filtration and plasma reinfusion | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 37238 | Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 37248 | Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 41512 | Tongue base suspension, permanent suture technique | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 41530 | Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 42145 | Palatopharyngoplasty | Standard Local Prior Authorization Code List, Pg 130 Original policy |
| 43284 | Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 43285 | Removal of esophageal sphincter augmentation device | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 43290 | Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 43291 | Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s) | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 43770 | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 43772 | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 43773 | Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 43774 | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 43842 | Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 43886 | Gastric restrictive procedure, open; revision of subcutaneous port component only | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 43887 | Gastric restrictive procedure, open; removal of subcutaneous port component only | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 43888 | Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 45560 | Repair of rectocele (separate procedure) | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 46707 | Repair of anorectal fistula with plug (eg, porcine small intestine submucosa [SIS]) | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 46948 | Hemorrhoidectomy, internal, by transanal hemorrhoidal dearterialization, 2 or more hemorrhoid columns/groups, including ultrasound guidance, with mucopexy, when performed | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 51715 | Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 53445 | Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 53446 | Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 53447 | Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session | Standard Local Prior Authorization Code List, Pg 131 Original policy |