Anthem Blue Cross Blue Shield of Georgia prior authorization, page 57
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 |
|---|---|---|
| 53449 | Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session including irrigation and debridement of infected tissue | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 53451 | Periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 53452 | Periurethral transperineal adjustable balloon continence device; unilateral insertion, including cystourethroscopy and imaging guidance | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 53453 | Periurethral transperineal adjustable balloon continence device; removal, each balloon | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 53454 | Periurethral transperineal adjustable balloon continence device; percutaneous adjustment of balloon(s) fluid volume | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 53860 | Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 54360 | Plastic operation on penis to correct angulation | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 54400 | Insertion of penile prosthesis; non-inflatable (semi- rigid) | Standard Local Prior Authorization Code List, Pg 131 Original policy |
| 54401 | Insertion of penile prosthesis; inflatable (self- contained) | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 54405 | Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 56810 | Perineoplasty, repair of perineum, nonobstetrical (separate procedure) | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 57240 | Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when performed | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 57250 | Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 57260 | Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 57268 | Repair of enterocele, vaginal approach (separate procedure) | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 57282 | Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus) | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 57283 | Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy) | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 57295 | Revision (including removal) of prosthetic vaginal graft, vaginal approach | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 57425 | Laparoscopy, surgical, colpopexy (suspension of vaginal apex) | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 58580 | Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 58674 | Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 61715 | MRI guided focused ultrasound high intensity stereotactic intracranial ablation | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 61885 | Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 62263 | Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 62264 | Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 62281 | Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 62282 | Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal) | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 62287 | Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 62291 | Injection procedure for discography, each level; cervical or thoracic | Standard Local Prior Authorization Code List, Pg 132 Original policy |
| 64405 | Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64415 | Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64417 | Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance, when performed | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64447 | Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance, when performed | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64450 | Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64454 | Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64510 | Injection, anesthetic agent; stellate ganglion (cervical sympathetic) | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64520 | Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64553 | Percutaneous implantation of neurostimulator electrode array; cranial nerve | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64555 | Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64568 | Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64569 | Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64575 | Incision for implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64590 | Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64596 | Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode array | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64624 | Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64628 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64640 | Destruction by neurolytic agent; other peripheral nerve or branch | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64716 | Neuroplasty and/or transposition; cranial nerve (specify) | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64722 | Decompression; unspecified nerve(s) (specify) | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64732 | Transection or avulsion of; supraorbital nerve | Standard Local Prior Authorization Code List, Pg 133 Original policy |