Anthem Blue Cross Blue Shield of Georgia prior authorization, page 8
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 |
|---|---|---|
| 38222 | Diagnostic bone marrow; biopsy(ies) and aspiration(s) | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 38500 | Bx/Excision, Lymph Node(S); Superficial | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 38505 | Bx/Excision, Lymph Node(S); Needle, Superficial | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 38510 | Bx/Excision, Lymph Node(S); Open, Deep Cervical Node(S) | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 38525 | Bx/Excision, Lymph Node(S); Open, Deep Axillary Node(S) | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 38740 | Axillary Lymphadenectomy; Superficial | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 38760 | Inguinofemoral lymphadenectomy, superficial, including Cloquet's node (separate procedure) | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 41019 | Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 43192 | Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 43201 | Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 43210 | Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 43229 | Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 43233 | Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 43235 | Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 43236 | Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 43239 | Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 43241 | Esophagogastroduodenoscopy, flexible, transoral; with insertion of intraluminal tube or catheter | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 43243 | Esophagogastroduodenoscopy, flexible, transoral; with injection, Sclerosis of esophageal/gastric varices | Standard Local Prior Authorization Code List, Pg 20 Original policy |
| 43244 | Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43245 | Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie) | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43246 | Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43247 | Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43248 | Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43249 | Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43250 | Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43251 | Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43254 | Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43255 | Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43257 | Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43266 | Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43270 | Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43281 | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of me | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43282 | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 43497 | Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM]) | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 46505 | Chemodenervation of internal anal sphincter | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 50542 | Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when performed | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 50592 | Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 50593 | Ablation, renal tumor(s), unilateral, presutaneous cryotherapy | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 51721 | Transurethral ablation transducer insertion for delivery of thermal ultrasound for prostate | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 52001 | Cystourethroscopy W/Irrigation & Evacuation Clots | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 52235 | Cystourethroscopy, W/Fulguration &/Or Resection; Bladder Tumor(S) 2.0-5.0 Cm | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 52287 | Cystourethroscopy, with injection(s) for chemodenervation of the bladder | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 52300 | Cystourethroscopy; W/Resection/Fulguration, Orthotopic Ureterocele(S), Unilat/Bilat | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 52450 | Transurethral Incision, Prostate | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 53850 | Transurethral destruction of prostate tissue; by microwave thermotherapy | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 53852 | Transurethral destruction of prostate tissue; by radiofrequency thermotherapy | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 54065 | Destruction, Penile Lesion, Extensive | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 54150 | Circumcision, using clamp or other device with regional dorsal penile or ring block | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 54161 | Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age | Standard Local Prior Authorization Code List, Pg 21 Original policy |
| 54162 | Lysis/Excision, Penile Postcircumcision Adhesions | Standard Local Prior Authorization Code List, Pg 21 Original policy |