Anthem Blue Cross Blue Shield of Georgia prior authorization, page 6
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 |
|---|---|---|
| 31237 | Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 31253 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 31254 | Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior) | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 31255 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 31256 | Nasal/sinus endoscopy, surgical, with maxillary antrostomy | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 31257 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 31259 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 31267 | Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 31276 | Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 31287 | Nasal/sinus endoscopy, surgical, with sphenoidotomy | Standard Local Prior Authorization Code List, Pg 12 Original policy |
| 31288 | Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 31295 | Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 31296 | Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation) | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 31297 | Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation) | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 31298 | Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (eg, balloon dilation) | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 31525 | Laryngoscopy Direct, W/Wo Tracheoscopy; Dx, Except Newborn | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 31574 | Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), unilateral | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 31591 | Laryngoplasty; medialization, unilateral | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 32408 | Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance, when performed | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 32555 | Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 32557 | Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 32701 | Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 32994 | Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 32998 | Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; radiofrequency | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 33206 | Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 33207 | Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 33212 | Insertion of pacemaker pulse generator only; with existing single lead | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 33213 | Insertion of pacemaker pulse generator only; with existing dual leads | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 33215 | Repositioning of Previously Implanted Transvenous Pacemaker or Pacing Cardioverter-Defibrillator Electrode | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 33218 | Repair of single transvenous electrode, permanent pacemaker or pacing cardioverter-defibrillator | Standard Local Prior Authorization Code List, Pg 13 Original policy |
| 33220 | Repair of 2 transvenous electrodes for permanent pacemaker or pacing cardioverter-defibrillator | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33222 | Relocation of skin pocket for pacemaker | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33227 | Removal Of Permanent Pacemaker Pulse Generator With Replacement Of Pacemaker Pulse Generator; Single Lead System | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33233 | Removal of permanent pacemaker pulse generator only | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33234 | Removal, Transvenous Pacemaker Electrode(S); Single Lead System, Atrial/Ventricular | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33235 | Removal, Transvenous Pacemaker Electrode(S); Dual Lead System | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33262 | Removal Of Pacing Cardioverter-Defibrillator Pulse Generator With Replacement Of Pacing Cardioverter-Defibrillator Pulse Generator; Single Lead System | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33276 | Insertion of phrenic nerve stimulator system (pulse generator and stimulating lead[s]), including vessel catheterization, all imaging guidance, and pulse generator initial analysis with diagnostic mode activation, when performed | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33278 | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; system, including pulse generator and lead(s) | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33279 | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) only | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33280 | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator only | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33281 | Repositioning of phrenic nerve stimulator transvenous lead(s) | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33285 | Insertion, subcutaneous cardiac rhythm monitor, including programming | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33287 | Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 33288 | Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 36260 | Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver) | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 36261 | Revision of implanted intra-arterial infusion pump | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 36465 | Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein) | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 36466 | Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg | Standard Local Prior Authorization Code List, Pg 14 Original policy |
| 36468 | Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk | Standard Local Prior Authorization Code List, Pg 15 Original policy |