Anthem Blue Cross Blue Shield of Georgia prior authorization, page 59
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 |
|---|---|---|
| 0071T | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 0072T | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 0101T | Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 0102T | Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 0106T | Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 0107T | Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 0108T | Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 0109T | Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 0110T | Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 0112U | Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug-resistance gene | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 0152U | Infectious disease (bacteria, fungi, parasites, and DNA viruses), microbial cell-free DNA, plasma, untargeted next-generation sequencing, report for significant positive pathogens | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 0207T | Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral | Standard Local Prior Authorization Code List, Pg 136 Original policy |
| 0253T | Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0255U | Andrology (infertility), sperm-capacitation assessment of ganglioside GM1 distribution patterns, fluorescence microscopy, fresh or frozen specimen, reported as percentage of capacitated sperm and probability of generating a pregnancy score | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0274T | Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracic | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0278T | Transcutaneous electrical modulation pain reprocessing (eg, scrambler therapy), each treatment session (includes placement of electrodes) | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0297U | Oncology (pan tumor), whole genome sequencing of paired malignant and normal DNA specimens, fresh or formalin-fixed paraffin-embedded (FFPE) tissue, blood or bone marrow, comp | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0298U | Oncology (pan tumor), whole transcriptome sequencing of paired malignant and normal RNA specimens, fresh or formalin-fixed paraffin- embedded (FFPE) tissue, blood or bone marro | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0299U | Oncology (pan tumor), whole genome optical genome mapping of paired malignant and normal DNA specimens, fresh frozen tissue, blood, or bone marrow, comparative structural vari | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0300U | Oncology (pan tumor), whole genome sequencing and optical genome mapping of paired malignant and normal DNA specimens, fresh tissue, blood, or bone marrow, comparative sequenc | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0323U | Infectious agent detection by nucleic acid (DNA and RNA), central nervous system pathogen, metagenomic next-generation sequencing, cerebrospinal fluid (CSF), identification of pathogenic bacteria, viruses, parasites, or fungi | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0330T | Tear film imaging, unilateral or bilateral, with interpretation and report | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0331T | Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0331U | Oncology (hematolymphoid neoplasia), optical genome mapping for copy number alterations and gene rearrangements utilizing DNA from blood or bone marrow, report of clinically s | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0332T | Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0334U | Oncology (solid organ), targeted genomic sequence analysis, formalin-fixed paraffin- embedded (FFPE) tumor tissue, DNA analysis, 84 or more genes, interrogation for sequence va | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0335T | Insertion of sinus tarsi implant | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0338T | Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0339T | Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; bilateral | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0342T | Therapeutic apheresis with selective HDL delipidation and plasma reinfusion | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0351T | Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative | Standard Local Prior Authorization Code List, Pg 137 Original policy |
| 0352T | Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; interpretation and report, real time or referred | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0353T | Optical coherence tomography of breast, surgical cavity; real time intraoperative | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0354T | Optical coherence tomography of breast, surgical cavity; interpretation and report, real time or referred | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0378T | Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0379T | Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0408T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0409T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0410T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode only | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0411T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0412T | Removal of permanent cardiac contractility modulation system; pulse generator only | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0413T | Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular) | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0414T | Removal and replacement of permanent cardiac contractility modulation system pulse generator only | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0415T | Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead) | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0416T | Relocation of skin pocket for implanted cardiac contractility modulation pulse generator | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0417T | Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation system | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0418T | Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable cardiac contractility modulation system | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0449T | Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0474T | Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0489T | Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cells | Standard Local Prior Authorization Code List, Pg 138 Original policy |