Anthem Blue Cross Blue Shield of Georgia prior authorization, page 58
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 |
|---|---|---|
| 64734 | Transection or avulsion of; infraorbital nerve | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64744 | Transection or avulsion of; greater occipital nerve | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64771 | Transection or avulsion of other cranial nerve, extradural | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 64772 | Transection or avulsion of other spinal nerve, extradural | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 66174 | Transluminal dilation of aqueous outflow canal; without retention of device or stent | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 66175 | Transluminal dilation of aqueous outflow canal; with retention of device or stent | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 66183 | Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 66683 | Iris prosthesis Implantation | Standard Local Prior Authorization Code List, Pg 133 Original policy |
| 66989 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 66991 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 67027 | Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of vitreous | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 67900 | Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 67901 | Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 67902 | Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 67903 | Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 67904 | Repair of blepharoptosis; (tarso) levator resection or advancement, external approach | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 67906 | Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 67908 | Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type) | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 69710 | Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 69714 | Implantation, osseointegrated implant, skull; with percutaneous attachment to external speech processor | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 69716 | Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or resulting in removal of less than 100 sq mm surface area of bone deep to the outer cranial cortex | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 69717 | Replacement (including removal of existing device), osseointegrated implant, skull; with percutaneous attachment to external speech processor | Standard Local Prior Authorization Code List, Pg 134 Original policy |
| 69719 | Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or involving a bony defect less than 100 sq mm surface area of bone deep to the outer cranial cortex | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 69729 | Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside of the mastoid and resulting in removal of greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 69730 | Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside the mastoid and involving a bony defect greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 69930 | Cochlear device implantation, with or without mastoidectomy | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 72285 | Discography, cervical or thoracic, radiological supervision and interpretation | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 76120 | Cineradiography/videoradiography, except where specifically included | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 77423 | High energy neutron radiation treatment delivery; 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 81595 | Cardiology (heart transplant), mRNA, gene expression profiling by real-time quantitative PCR of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral b | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 86357 | Natural killer (NK) cells, total count | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 89329 | Sperm evaluation; hamster penetration test | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 89330 | Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 90901 | Biofeedback training by any modality | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 90912 | Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 91112 | Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 93228 | External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 93229 | External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 93264 | Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure recordings, interpretation(s), trend analysis, and report(s) by a physician or other qualified health care | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 93580 | Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 93640 | Electrophys Eval, Single/Dual Pacing Cardio/Defib Leads, Initial Implant/Replace | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 93641 | Electrophys Eval, Single/Dual Pacing Cardio/Defib Leads, Initial Implant/Replace; W/Pulse Generator | Standard Local Prior Authorization Code List, Pg 135 Original policy |
| 93701 | Bioimpedance-derived physiologic cardiovascular analysis | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 95905 | Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 95976 | Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 95977 | Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 96904 | Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 96931 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 96932 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, first lesion | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 96933 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, first lesion | Standard Local Prior Authorization Code List, Pg 136 Original policy |