Anthem Blue Cross Blue Shield of Georgia prior authorization, page 7
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 |
|---|---|---|
| 36470 | Injection of sclerosant; single incompetent vein (other than telangiectasia) | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36471 | Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36473 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36475 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36478 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36482 | Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36556 | Insertion of Non-Tunneled Centrally Inserted Central Venous Catheter; Age 5 Years or Older | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36563 | Insertion of tunneled centrally inserted central venous access device with subcutaneous pump | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36571 | Insertion of Peripherally Inserted Central Venous Access Device, with Subcutaneous Port; Age 5 Years or Older | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36581 | Replacement, Complete, of a Tunneled Centrally Inserted Central Venous Catheter, wo Sq Port or Pump, Via Same Access | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36582 | Replacement, Complete, of a Tunneled Centrally Inserted Central Venous Access Device, w Sq Port, Via Same Access | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36583 | Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous pump, through same venous access | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36589 | Removal of Tunneled Central Venous Catheter, without Subcutaneous Port or Pump | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36590 | Removal of Tunneled Central Venous Access Device, with Subcutaneous Port or Pump, Central or Peripheral Insertion | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36821 | Arteriovenous Anastomosis, Open; Direct, Any Site (Sep Proc) | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36901 | Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report | Standard Local Prior Authorization Code List, Pg 15 Original policy |
| 36902 | Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty | Standard Local Prior Authorization Code List, Pg 16 Original policy |
| 36903 | Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment | Standard Local Prior Authorization Code List, Pg 16 Original policy |
| 36905 | Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty | Standard Local Prior Authorization Code List, Pg 16 Original policy |
| 36906 | Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis circuit | Standard Local Prior Authorization Code List, Pg 16 Original policy |
| 37241 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) | Standard Local Prior Authorization Code List, Pg 16 Original policy |
| 37242 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) | Standard Local Prior Authorization Code List, Pg 16 Original policy |
| 37243 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction | Standard Local Prior Authorization Code List, Pg 16 Original policy |
| 37244 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation | Standard Local Prior Authorization Code List, Pg 16 Original policy |
| 37254 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 17 Original policy |
| 37256 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 17 Original policy |
| 37258 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 17 Original policy |
| 37260 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 17 Original policy |
| 37263 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 17 Original policy |
| 37265 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 17 Original policy |
| 37267 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 17 Original policy |
| 37269 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 18 Original policy |
| 37271 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 18 Original policy |
| 37273 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 18 Original policy |
| 37275 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement, atherectomy, and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 18 Original policy |
| 37277 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement, atherectomy, and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 18 Original policy |
| 37280 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 18 Original policy |
| 37282 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 18 Original policy |
| 37284 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 19 Original policy |
| 37286 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 19 Original policy |
| 37288 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 19 Original policy |
| 37290 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 19 Original policy |
| 37292 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement, atherectomy, and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 19 Original policy |
| 37294 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement, atherectomy, and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 19 Original policy |
| 37296 | Revascularization, endovascular, open or percutaneous, inframalleolar vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 19 Original policy |
| 37298 | Revascularization, endovascular, open or percutaneous, inframalleolar vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, initial vessel | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 37607 | Ligation/Banding, Angioaccess Arteriovenous Fistula | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 37609 | Ligation/Bx, Temporal Artery | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 37761 | Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 38221 | Diagnostic bone marrow; biopsy(ies) | Standard Local Prior Authorization Code List, Pg 20 Original policy |