Anthem Blue Cross Blue Shield of Georgia prior authorization, page 65
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 |
|---|---|---|
| Q4137 | AmnioExCel, AmnioExCel plus or BioDExCel, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4138 | BioDfence Dryflex, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4139 | AmnioMatrix or BioDMatrix, injectable, 1 cc | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4140 | BioDfence, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4141 | Alloskin AC, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4142 | XCM Biologic Tissue Matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4143 | Repriza, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4145 | Epifix, injectable, 1 mg | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4146 | TenSIX, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4147 | Architect, Architect PX, or Architect FX, extracellular matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4148 | NEOX Cord 1k, NEOX Cord RT, or Clarix Cord 1k, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4149 | Excellagen, 0.1 cc | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4150 | Allowrap DS or Dry, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4152 | DermaPure, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4153 | Dermavest and Plurivest, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4155 | NeoxFlo or ClarixFlo, 1 mg | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4156 | NEOX 100 or Clarix 100, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4157 | Revitalon, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4159 | Affinity, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4161 | Bio-connekt wound matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4162 | WoundEx Flow, BioSkin Flow, 0.5 cc | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4163 | WoundEx, BioSkin, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4164 | Helicoll, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4165 | Keramatrix or Kerasorb, per square centimeter | Standard Local Prior Authorization Code List, Pg 149 Original policy |
| Q4166 | Cytal, per square centimeter [formerly Matristem wound/burn matrix] | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4167 | TruSkin, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4169 | Artacent Wound, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4170 | CYGNUS, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4171 | Interfyl, 1 mg | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4173 | PalinGen or PalinGen Xplus, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4174 | PalinGen or ProMatrX, 0.36 mg per 0.25 cc | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4175 | Miroderm, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4176 | NeoPatch or Therion, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4177 | FlowerAmnioflo, 0.1 cc | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4178 | FlowerAmniopatch, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4179 | FlowerDerm, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4180 | Revita, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4181 | Amnio Wound, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4183 | Surgigraft, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4184 | Cellesta or Cellesta Duo, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4185 | Cellesta flowable amnion (25 mg per cc); per 0.5 cc | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4188 | Amnioarmor, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4189 | Artacent AC, 1 mg | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4190 | Artacent AC, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4191 | Restorigin, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4192 | Restorigin, 1 cc | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4193 | Coll-e-derm, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4194 | Novachor, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4195 | Puraply, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4196 | PuraPly AM, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |