Anthem Blue Cross Blue Shield of Georgia prior authorization, page 67
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 |
|---|---|---|
| Q4254 | Novafix dl, per square centimeter | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4255 | Reguard, for topical use only, per square centimeter | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4256 | MLG-Complete, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4257 | Relese, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4258 | Enverse, per sq cm | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4259 | Celera dual layer or celera dual membrane, per square centimeter | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4260 | Signature apatch, per square centimeter | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4261 | Tag, per square centimeter | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4262 | Dual Layer Impax Membrane, per square centimeter | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4263 | SurGraft TL, per square centimeter | Standard Local Prior Authorization Code List, Pg 151 Original policy |
| Q4264 | Cocoon membrane, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4265 | NeoStim TL, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4266 | NeoStim Membrane, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4267 | NeoStim DL, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4268 | SurGraft FT, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4269 | SurGraft XT, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4270 | Complete SL, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4271 | Complete FT, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4272 | Esano A, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4273 | Esano AAA, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4274 | Esano AC, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4275 | Esano ACA, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4276 | ORION, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4278 | EPIEFFECT, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4279 | Vendaje ac, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4280 | Xcell Amnio Matrix, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4281 | Barrera SL or Barrera DL, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4282 | Cygnus Dual, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4284 | DermaBind SL, per sq cm | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4287 | Dermabind dl, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4288 | Dermabind dl, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4289 | Dermabind ch, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4290 | Revoshield + amniotic barrier, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4291 | Lamellas xt, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4292 | Lamellas, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4293 | Acesso dl, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4294 | Amnio quad-core, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4295 | Amnio tri-core amniotic, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4296 | Rebound matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4297 | Emerge matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4298 | Amnicore pro, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4299 | Amnicore pro+, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4300 | Acesso tl, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4301 | Activate matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4302 | Complete aca, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4303 | Complete aa, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4304 | Grafix plus, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4310 | Procenta, per 100 mg | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4346 | Shelter dm matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4347 | Rampart dl matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |