Anthem Blue Cross Blue Shield of Georgia prior authorization, page 62
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 |
|---|---|---|
| B4193 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4197 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4199 | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, over 100 grams of protein - premix | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4216 | Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) home mix per day | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4220 | Parenteral nutrition supply kit; premix, per day | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4222 | Parenteral nutrition supply kit; home mix, per day | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B4224 | Parenteral nutrition administration kit, per day | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B5000 | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - Aminosyn-RF, NephrAmine, RenAmine - premix | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B5100 | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic, HepatAmine - premix | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B5200 | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-branch chain amino acids - FreAmine-HBC - premix | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B9004 | Parenteral nutrition infusion pump, portable | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| B9006 | Parenteral nutrition infusion pump, stationary | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| C1735 | Catheter(s), intravascular for renal denervation, radiofrequency, including all single use system components | Standard Local Prior Authorization Code List, Pg 143 Original policy |
| C1736 | Catheter(s), intravascular for renal denervation, ultrasound, including all single use system components | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C1763 | Connective tissue, nonhuman (includes synthetic) | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C1767 | Generator, neurostimulator (implantable), nonrechargeable | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C1778 | Lead, neurostimulator (implantable) | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C1787 | Patient programmer, neurostimulator | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C1815 | Prosthesis, urinary sphincter (implantable) | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C1820 | Generator, neurostimulator (implantable), with rechargeable battery and charging system | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C1821 | Interspinous process distraction device (implantable) | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C1824 | Generator, cardiac contractility modulation (implantable) | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C1825 | Generator, neurostimulator (implantable), non- rechargeable with carotid sinus baroreceptor stimulation lead(s) | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C1833 | Monitor, cardiac, including intracardiac lead and all system components (implantable) | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C1839 | Iris prosthesis | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C1878 | Material for vocal cord medialization, synthetic (implantable) | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C2622 | Prosthesis, penile, noninflatable | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C2624 | Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C7531 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal angioplasty with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C7534 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with atherectomy, includes angioplasty within the same vessel, when performed with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C7535 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal stent placement(s), includes angioplasty within the same vessel, when performed, with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C7538 | Insertion of new or replacement of permanent pacemaker with ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricul | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C7539 | Insertion of new or replacement of permanent pacemaker with atrial and ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for lef | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C7540 | Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, dual lead system, with insertion of pacing electrode, cardiac venous system, for | Standard Local Prior Authorization Code List, Pg 144 Original policy |
| C9352 | Microporous collagen implantable tube (NeuraGen Nerve Guide), per centimeter length | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| C9353 | Microporous collagen implantable slit tube (NeuraWrap Nerve Protector), per centimeter length | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| C9354 | Acellular pericardial tissue matrix of non-human origin (Veritas), per square centimeter | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| C9355 | Collagen nerve cuff (NeuroMatrix), per 0.5 centimeter length | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| C9356 | Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector Sheet), per square centimeter | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| C9361 | Collagen matrix nerve wrap (NeuroMend Collagen Nerve Wrap), per 0.5 centimeter length | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| C9364 | Porcine implant, Permacol, per square centimeter | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| C9727 | Insertion of implants into the soft palate; minimum of 3 implants | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| C9734 | Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (mr) guidance | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| C9807 | Nerve stimulator, percutaneous, peripheral (e.g., sprint peripheral nerve stimulation system), including electrode and all disposable system components, non-opioid medical dev | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| D7940 | Osteoplasty - For Orthognathic Deformities | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| D7941 | Osteotomy - Mandibular Rami | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| D7943 | Osteotomy - Mandibular Rami With Bone Graft; Includes Obtaining The Graft | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| D7944 | OSTEOTOMY-SEGMENTED OR SUBAPICAL | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| D7945 | osteotomy - body of mandible | Standard Local Prior Authorization Code List, Pg 145 Original policy |
| D7946 | LeFort I (maxilla - total) | Standard Local Prior Authorization Code List, Pg 145 Original policy |