Anthem Blue Cross Blue Shield of Georgia prior authorization, page 66
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 |
|---|---|---|
| Q4197 | PuraPly XT, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4198 | Genesis amniotic membrane, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4199 | Cygnus matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4200 | SkinTE, per sq cm | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4201 | Matrion, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4202 | Keroxx (2.5g/cc), 1cc | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4203 | Derma-gide, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4204 | Xwrap, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4205 | Membrane Graft or Membrane Wrap, per sq cm | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4206 | Fluid Flow or Fluid GF, 1 cc | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4208 | Novafix, per sq cm | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4209 | SurGraft, per square centimeter | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4211 | Amnion Bio or AxoBioMembrane, per sq cm | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4212 | AlloGen, per cc | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4213 | Ascent, 0.5 mg | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4214 | Cellesta Cord, per sq cm | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4215 | Axolotl Ambient or Axolotl Cryo, 0.1 mg | Standard Local Prior Authorization Code List, Pg 150 Original policy |
| Q4216 | Artacent Cord, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4217 | WoundFix, BioWound, WoundFix Plus, BioWound Plus, WoundFix Xplus or BioWound Xplus, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4218 | SurgiCORD, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4219 | SurgiGRAFT-DUAL, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4220 | BellaCell HD or Surederm, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4221 | Amnio Wrap2, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4222 | ProgenaMatrix, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4224 | Human Health Factor 10 Amniotic Patch (HHF10- P), per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4225 | Amniobind or dermabind tl, per square centimeter | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4226 | MyOwn Skin, includes harvesting and preparation procedures, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4227 | AmnioCoreTM, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4229 | Cogenex Amniotic Membrane, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4230 | Cogenex Flowable Amnion, per 0.5 cc | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4232 | Corplex, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4233 | SurFactor or NuDyn, per 0.5 cc | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4234 | XCellerate, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4235 | AMNIOREPAIR or AltiPly, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4236 | CarePATCH, per square centimeter | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4237 | Cryo-Cord, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4238 | Derm-Maxx, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4239 | Amnio-Maxx or Amnio-Maxx Lite, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4240 | CoreCyte, for topical use only, per 0.5 cc | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4241 | PolyCyte, for topical use only, per 0.5 cc | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4242 | AmnioCyte Plus, per 0.5 cc | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4245 | AmnioText, per cc | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4246 | CoreText or ProText, per cc | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4247 | Amniotext patch, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4248 | Dermacyte Amniotic Membrane Allograft, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4249 | Amniply, for topical use only, per square centimeter | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4250 | Amnioamp-mp, per square centimeter | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4251 | Vim, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4252 | Vendaje, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4253 | Zenith Amniotic Membrane, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |