Anthem Blue Cross Blue Shield of Georgia prior authorization, page 69
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 |
|---|---|---|
| S2080 | Laser-assisted uvulopalatoplasty (LAUP) | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S2117 | Arthroereisis, subtalar | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S2230 | Implantation of magnetic component of semi- implantable hearing device on ossicles in middle ear | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S2300 | Arthroscopy, shoulder, surgical; with thermally- induced capsulorrhaphy | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S2348 | Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S3900 | Surface electromyography (EMG) | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S8130 | Interferential current stimulator, 2 channel | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S8131 | Interferential current stimulator, 4 channel | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S8930 | Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with patient | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S9056 | Coma stimulation per diem | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S9090 | Vertebral axial decompression, per session | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S9364 | Home infusion therapy, total parenteral nutrition (TPN) (do not use with home infusion codes S9365- S9368 using daily vol | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S9365 | Home infusion therapy, total parenteral nutrition (TPN); one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula, and nursing visits coded separately) per diem | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S9366 | Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula, and nursing visits coded separately) per diem | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S9367 | Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula, and nursing visits coded separately) per diem | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| S9368 | Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula, and nursing visits coded separately) per diem | Standard Local Prior Authorization Code List, Pg 154 Original policy |
| V5095 | Semi-implantable middle ear hearing prosthesis | Standard Local Prior Authorization Code List, Pg 154 Original policy |