Anthem Blue Cross Blue Shield of Georgia prior authorization, page 68
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 |
|---|---|---|
| Q4348 | Sentry sl matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4349 | Mantle dl matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4350 | Palisade dm matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 152 Original policy |
| Q4351 | Enclose tl matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4352 | Overlay sl matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4353 | Xceed tl matrix, per square centimeter | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4354 | Palingen dual-layer membrane and dual-layer palingen x-membrane, per square centimeter (add- on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4355 | Abiomend xplus membrane and abiomend xplus hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4356 | Abiomend membrane and abiomend hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4357 | Xwrap plus, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4358 | Xwrap dual, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4359 | Choriply, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4360 | Amchoplast fd, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4361 | Epixpress, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4362 | Cygnus disk, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4363 | Amnio burgeon membrane and hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4364 | Amnio burgeon xplus membrane and xplus hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4365 | Amnio burgeon dual-layer membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4366 | Dual layer amnio burgeon x-membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q4367 | Amniocore sl, per square centimeter (add-on, list separately in addition to primary procedure) | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5101 | Injection, filgrastim-sndz, biosimilar, (Zarxio), 1 mcg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5105 | Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for ESRD on dialysis), 100 units | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5106 | Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for non-ESRD use), 1000 units | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5107 | Injection, bevacizumab-awwb, biosimilar, (Mvasi), 10 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5108 | Injection, pegfilgrastim-jmdb (Fulphila), biosimilar, 0.5 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5110 | Injection, filgrastim-aafi, biosimilar, (Nivestym), 1 mcg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5111 | Injection, pegfilgrastim-cbqv, biosimilar, (Udenyca), 0.5 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5115 | Injection, rituximab-abbs, biosimilar, (Truxima), 10 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5118 | Injection, bevacizumab-bvcr, biosimilar, (Zirabev), 10 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5119 | Injection, rituximab-pvvr, biosimilar, (RUXIENCE), 10 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5120 | Injection, pegfilgrastim-bmez, biosimilar, (ZIEXTENZO), 0.5 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5122 | Injection, pegfilgrastim-apgf (Nyvepria), biosimilar, 0.5 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5125 | Injection, filgrastim-ayow, biosimilar, (Releuko), 1 mcg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5126 | Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5127 | Injection, pegfilgrastim-fpgk (stimufend), biosimilar, 0.5 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5129 | Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5130 | Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5133 | Injection, tocilizumab-bavi (Tofidence), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5135 | Injection, tocilizumab-aazg (Tyenne), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5136 | Injection, denosumab-bbdz (Jubbonti/Wyost), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5148 | Injection, filgrastim-txid (Nypozi), biosimilar, 1 mcg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5156 | Injection, tocilizumab-anoh (Avtozma), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 153 Original policy |
| Q5157 | Injection, denosumab-bmwo (Stoboclo/Osenvelt), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| Q5158 | Injection, denosumab-bnht (Bomyntra/Conexxence), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| Q5159 | Injection, denosumab-dssb (Ospomyv/Xbryk), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| Q5166 | Injection, denosumab-desu (osvyrti/jubereq), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| Q5167 | Injection, denosumab-qbde (enoby/xtrenbo), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| Q5169 | Injection, pegfilgrastim-unne (armlupeg), biosimilar, 0.5 mg | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| Q5171 | Injection, denosumab-mobz (boncresa), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S1091 | Stent, non-coronary, temporary, with delivery system (Propel) | Standard Local Prior Authorization Code List, Pg 154 Original policy |