Anthem Blue Cross Blue Shield of Georgia prior authorization, page 63
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 |
|---|---|---|
| D7947 | Lefort I (Maxilla - Segmented) | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| D7948 | LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| D7949 | Lefort II Or Lefort III - With Bone Graft | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| D7950 | Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| D7995 | Synthetic Graft - Mandible Or Facial Bones, By Report | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| D7996 | Implant-Mandible For Augmentation Purposes (Excluding Alveolar Ridge), By Report | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| E0732 | Cranial electrotherapy stimulation (CES) system, any type | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| E1399 | Durable medical equipment, miscellaneous | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| E1905 | Virtual reality cognitive behavioral therapy device (CBT), including preprogrammed therapy software | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| G0255 | Current perception threshold/sensory nerve conduction test (SNCT), per limb, any nerve | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| G0428 | Collagen meniscus implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex) | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| G0429 | Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J0881 | Injection, darbepoetin alfa, 1 mcg (non-ESRD use) | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J0882 | Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis) | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J0885 | Injection, epoetin alfa, (for non-ESRD use), 1000 units | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J0896 | Injection, luspatercept-aamt, 0.25 mg | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J0897 | Injection, denosumab, 1 mg | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J1442 | Injection, filgrastim (G-CSF), excludes biosimilars, 1 mcg | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J1447 | Injection, tbo-filgrastim, 1 microgram | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J1449 | Injection, eflapegrastim-xnst, 0.1 mg | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J1459 | Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J1460 | Injection, gamma globulin, intramuscular, 1 cc | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J1551 | Injection, immune globulin (cutaquig), 100 mg | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J1552 | Injection, immune globulin (Alyglo), 500 mg(cid:9) | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J1554 | Injection, immune globulin (asceniv), 500 mg | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J1555 | Injection, immune globulin (Cuvitru), 100 mg | Standard Local Prior Authorization Code List, Pg 146 Original policy |
| J1556 | Injection, immune globulin (Bivigam), 500 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1557 | Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1558 | Injection, immune globulin (xembify), 100 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1559 | Injection, immune globulin (Hizentra), 100 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1560 | Injection, gamma globulin, intramuscular, over 10 cc | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1561 | Injection, immune globulin, (Gamunex/Gamunex- C/Gammaked), nonlyophilized (e.g., liquid), 500 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1566 | Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1568 | Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1569 | Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1572 | Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1575 | Injection, immune globulin/hyaluronidase, 100 mg immuneglobulin | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1576 | Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1577 | Injection, immune globulin (qivigy), 100 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1930 | Injection, lanreotide, 1 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J1932 | Injection, lanreotide, (Cipla), 1 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J2353 | Injection, octreotide, depot form for intramuscular injection, 1 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J2354 | Injection, octreotide, nondepot form for subcutaneous or intravenous injection, 25 mcg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J2506 | Injection, pegfilgrastim, excludes biosimilar, 0.5 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J2562 | Injection, plerixafor, 1 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J2779 | Injection, ranibizumab, via intravitreal implant (Susvimo), 0.1 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J2802 | Injection, romiplostim, 1 mcg(cid:9) | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J2820 | Injection, sargramostim (GM-CSF), 50 mcg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J3262 | Injection, tocilizumab, 1 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J3490 | Unclassified drugs | Standard Local Prior Authorization Code List, Pg 147 Original policy |