Anthem Blue Cross Blue Shield of Georgia prior authorization, page 60
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 |
|---|---|---|
| 0490T | Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands | Standard Local Prior Authorization Code List, Pg 138 Original policy |
| 0505T | Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0510T | Removal of sinus tarsi implant | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0511T | Removal and reinsertion of sinus tarsi implant | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0512T | Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0515T | Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; complete system (includes electrode and generator [transmitter and battery]) | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0516T | Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; electrode only | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0517T | Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; pulse generator component(s) (battery and/or transmitter) only | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0519T | Removal and replacement of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; both components (battery and transmitter) | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0520T | Removal and replacement of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; battery component only | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0525T | Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; complete system (electrode and implantable monitor) | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0526T | Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; electrode only | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0527T | Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; implantable monitor only | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0528T | Programming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and report | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0529T | Interrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and report | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0530T | Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; complete system (electrode and implantable monitor) | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0531T | Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; electrode only | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0532T | Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; implantable monitor only | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0546T | Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0563T | Evacuation of meibomian glands, using heat delivered through wearable, open-eye eyelid treatment devices and manual gland expression, bilateral | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0565T | Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation | Standard Local Prior Authorization Code List, Pg 139 Original policy |
| 0566T | Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0596T | Temporary female intraurethral valve-pump (ie, voiding prosthesis); initial insertion, including urethral measurement | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0597T | Temporary female intraurethral valve-pump (ie, voiding prosthesis); replacement | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0600T | Ablation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance, when performed, percutaneous | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0601T | Ablation, irreversible electroporation; 1 or more tumors, including fluoroscopic and ultrasound guidance, when performed, open | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0607T | Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ECG data), transmitted to a remote 24-hour attended surveillance center; set-up and patient education on use of equipment | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0608T | Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ECG data), transmitted to a remote 24-hour attended surveillance center; analysis of data received and transmission of reports to the physician or other qualified health care professional | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0615T | Eye-movement analysis without spatial calibration, with interpretation and report | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0620T | Endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0655T | Transperineal focal laser ablation of malignant prostate tissue, including transrectal imaging guidance, with MR-fused images or other enhanced ultrasound imaging | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0658T | Electrical impedance spectroscopy of 1 or more skin lesions for automated melanoma risk score | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0671T | Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0672T | Endovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0689T | Quantitative ultrasound tissue characterization (non- elastographic), including interpretation and report, obtained without diagnostic ultrasound examination of the same anatomy (eg, organ, gland, tissue, target structure) | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0700T | Molecular fluorescent imaging of suspicious nevus; first lesion | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0717T | Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, including incubation with cell dissociation enzymes, filtration, washing and concentration of ADRCs | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0718T | Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilateral | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0736T | Colonic lavage, 35 or more liters of water, gravity- fed, with induced defecation, including insertion of rectal catheter | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0745T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image data (eg, CT, MRI, or myocardial perfusion scan) and electrical data (eg, 12-lead ECG data), and identification of areas of avoidance | Standard Local Prior Authorization Code List, Pg 140 Original policy |
| 0746T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiation treatment plan | Standard Local Prior Authorization Code List, Pg 141 Original policy |
| 0747T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia | Standard Local Prior Authorization Code List, Pg 141 Original policy |
| 0766T | Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, with identification and mapping of the treatment location, including noninvasive electroneurographic localization (nerve conduction localization), when performed; first nerve | Standard Local Prior Authorization Code List, Pg 141 Original policy |
| 0771T | Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of dissociation or consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older | Standard Local Prior Authorization Code List, Pg 141 Original policy |
| 0773T | Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; initial 15 minutes of intraservice time, patient age 5 years or older | Standard Local Prior Authorization Code List, Pg 141 Original policy |
| 0778T | Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscle function | Standard Local Prior Authorization Code List, Pg 141 Original policy |
| 0795T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; complete system (ie, right atrial and right ventricular pacemaker components) | Standard Local Prior Authorization Code List, Pg 141 Original policy |
| 0796T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right atrial pacemaker component (when an existing right ventricular single leadless pacemaker exists to create a dual-chamber leadless pacemaker system) | Standard Local Prior Authorization Code List, Pg 141 Original policy |
| 0797T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right ventricular pacemaker component (when part of a dual-chamber leadless pacemaker system) | Standard Local Prior Authorization Code List, Pg 141 Original policy |
| 0800T | Transcatheter removal of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography), when performed; right ventricular pacemaker component (when part of a dual- chamber leadless pacemaker system) | Standard Local Prior Authorization Code List, Pg 141 Original policy |