Anthem Blue Cross Blue Shield of Georgia prior authorization, page 61
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 |
|---|---|---|
| 0801T | Transcatheter removal and replacement 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; dual-chamber system (ie, right atrial and right ventricular pacemaker components) | Standard Local Prior Authorization Code List, Pg 141 Original policy |
| 0802T | Transcatheter removal and replacement 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 | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| 0803T | Transcatheter removal and replacement 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 142 Original policy |
| 0864T | Low-intensity extracorporeal shock wave therapy involving corpus cavernosum, low energy | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| 0935T | Cystourethroscopy with renal pelvic sympathetic denervation, radiofrequency ablation, retrograde ureteral approach, including insertion of guide wire, selective placement of u | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| 0948T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation system with interim analysis, review and report(s) by a physician or other qualified | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| 0949T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation system, remote data acquisition(s), receipt of transmissions, technician review, tech | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| 0951T | Totally implantable active middle ear hearing implant; initial placement, including mastoidectomy, placement of and attachment to sound processor | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| 0952T | Totally implantable active middle ear hearing implant; revision or replacement, with mastoidectomy and replacement of sound processor | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| 0953T | Totally implantable active middle ear hearing implant; revision or replacement, without mastoidectomy and replacement of sound processor | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| 0954T | Totally implantable active middle ear hearing implant; replacement of sound processor only, with attachment to existing transducers | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| 0955T | Totally implantable active middle ear hearing implant; removal, including removal of sound processor and all implant components | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| 0978T | Submucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| 0979T | Submucosal cryolysis therapy; soft palate only | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| 0980T | Submucosal cryolysis therapy; base of tongue and lingual tonsil only | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2001 | InnovaMatrix AC, per sq cm | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2002 | Mirragen Advanced Wound Matrix, per sq cm | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2004 | XCelliStem, 1 mg | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2005 | Microlyte Matrix, per sq cm | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2006 | NovoSorb SynPath dermal matrix, per sq cm | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2007 | Restrata, per sq cm | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2008 | TheraGenesis, per sq cm | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2009 | Symphony, per sq cm | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2010 | Apis, per sq cm | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2011 | Supra SDRM, per sq cm | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2012 | SUPRATHEL, per sq cm | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2013 | Innovamatrix FS, per sq cm | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2014 | Omeza Collagen Matrix, per 100 mg | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2015 | Phoenix Wound Matrix, per sq cm | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2016 | PermeaDerm B, per sq cm | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2017 | PermeaDerm Glove, each | Standard Local Prior Authorization Code List, Pg 142 Original policy |
| A2018 | PermeaDerm C, per sq cm | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| A2019 | Kerecis Omega3 MariGen Shield, per sq cm | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| A2020 | AC5 Advanced Wound System (AC5) | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| A2021 | NeoMatriX, per sq cm | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| A2025 | Miro3D, per cu cm | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| A2030 | Miro3D fibers, per mg | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| A2031 | Mirodry wound matrix, per square centimeter (add- on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| A2032 | Myriad matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| A2033 | Myriad Morcells, 4 mg | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| A2034 | Foundation drs solo, per square centimeter (add- on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| A2035 | Corplex P or Theracor P or Allacor P, per mg | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4164 | Parenteral nutrition solution; carbohydrates (dextrose), 50% or less (500 ml = 1 unit) - home mix | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4168 | Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) - home mix | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4176 | Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mix | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4178 | Parenteral nutrition solution; amino acid, greater than 8.5%, (500 ml = 1 unit) - home mix | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4180 | Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) - home mix | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4185 | Parenteral nutrition solution, not otherwise specified, 10 grams lipids | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4187 | Omegaven, 10 grams lipids | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4189 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix | Standard Local Prior Authorization Code List, Pg 143 Original policy |