Anthem Blue Cross Blue Shield of Georgia prior authorization, page 64
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 |
|---|---|---|
| J3590 | Unclassified Biologics | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J7402 | Mometasone furoate sinus implant, (Sinuva), 10 mcg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J9033 | Injection, bendamustine HCl (Treanda), 1 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J9034 | Injection, bendamustine hcl (bendeka), 1 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J9035 | Injection, bevacizumab, 10 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J9036 | Injection, bendamustine hydrochloride, (Belrapzo), 1 mg | Standard Local Prior Authorization Code List, Pg 147 Original policy |
| J9043 | Injection, cabazitaxel, 1 mg | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| J9056 | Injection, bendamustine hydrochloride (vivimusta), 1 mg | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| J9266 | Injection, pegaspargase, per single dose vial | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| J9301 | Injection, obinutuzumab, 10 mg | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| J9305 | Injection, pemetrexed, NOS, 10 mg | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| J9354 | Injection, ado-trastuzumab emtansine, 1 mg | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| J9361 | Injection, efbemalenograstim alfa-vuxw, 0.5 mg | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| K1030 | External recharging system for battery (internal) for use with implanted cardiac contractility modulation generator, replacement only | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8607 | Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8614 | Cochlear device, includes all internal and external components | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8619 | Cochlear implant, external speech processor and controller, integrated system, replacement | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8627 | Cochlear implant, external speech processor, component, replacement | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8628 | Cochlear implant, external controller component, replacement | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8678 | Electrical stimulator supplies (external) for use with implantable neurostimulator, per month | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8679 | Implantable neurostimulator, pulse generator, any type | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8680 | Implantable neurostimulator electrode, each | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8681 | Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8682 | Implantable neurostimulator radiofrequency receiver | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8683 | Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8685 | Implantable neurostimulator pulse generator, single array, rechargeable, includes extension | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8686 | Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8688 | Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8690 | Auditory osseointegrated device, includes all internal and external components | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8691 | Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8692 | Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| L8693 | Auditory osseointegrated device abutment, any length, replacement only | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| Q2026 | Injection, Radiesse, 0.1ml | Standard Local Prior Authorization Code List, Pg 148 Original policy |
| Q2028 | Injection, sculptra, 0.5 mg | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q2043 | Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4081 | Injection, epoetin alfa, 100 units (for ESRD on dialysis) | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4103 | Oasis Burn Matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4108 | Integra Matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4111 | Gammagraft, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4113 | Graftjacket Xpress, injectable, 1 cc | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4114 | Integra Flowable Wound Matrix, injectable, 1 cc | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4117 | Hyalomatrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4118 | Matristem micromatrix, 1 mg | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4123 | AlloSkin RT, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4125 | ArthroFlex, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4126 | Memoderm, dermaspan, tranzgraft or integuply, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4127 | Talymed, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4132 | Grafix CORE and GrafixPL CORE, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4134 | hMatrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4135 | Mediskin, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |