Anthem Blue Cross Blue Shield of Georgia prior authorization, page 9
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 |
|---|---|---|
| 54163 | Repair, Incomplete Circumcision | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 54164 | Frenulotomy, Penis | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 54300 | Plastic Operation, Penis, Straightening, Chordee, W/Wo Mobilization, Urethra | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 54410 | Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 54411 | Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 54416 | Removal and replacement of non-inflatable (semi- rigid) or inflatable (self-contained) penile prosthesis at the same operative session | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 54417 | Removal and replacement of non-inflatable (semi- rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 54450 | Foreskin Manipulation W/Lysis, Preputial Adhesions & Stretching | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 54840 | Excision, Spermatocele, W/Wo Epididymectomy | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 55040 | Excision, Hydrocele; Unilat | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 55041 | Excision, Hydrocele; Bilat | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 55707 | Biopsy, prostate, transrectal, ultrasound-guided (ie, sextant, ultrasound-localized discrete lesion[s]) | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 55708 | Biopsy, prostate, transrectal, ultrasound-guided (ie, sextant) with MRI-fusion-guidance, first targeted lesion | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 55709 | Biopsy, prostate, transperineal, ultrasound-guided (ie, sextant, ultrasound-localized discrete lesion[s]) | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 55710 | Biopsy, prostate, transperineal, ultrasound-guided (ie, sextant) with MRI-fusion-guidance biopsy, first targeted lesion | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 55711 | Biopsy, prostate, transrectal, MRI-ultrasound-fusion guided, targeted lesion(s) only, first targeted lesion | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 55712 | Biopsy, prostate, transperineal, MRI-ultrasound- fusion guided, targeted lesion(s) only, first targeted lesion | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 55713 | Biopsy, prostate, in-bore CT- or MRI-guided (ie, sextant), with biopsy of additional targeted lesion(s), first targeted lesion | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 55714 | Biopsy, prostate, in-bore CT- or MRI-guided targeted lesion(s) only, first targeted lesion | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 55860 | Exposure of prostate, any approach, for insertion of radioactive substance | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 55873 | Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) | Standard Local Prior Authorization Code List, Pg 22 Original policy |
| 55874 | Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 55875 | Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 55880 | Ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 55881 | Transurethral ablation of prostate tissue, using thermal ultrasound | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 55882 | Transurethral ablation of prostate tissue, using thermal ultrasound; with insertion of ultrasound transducer | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 55920 | Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 57155 | Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 57156 | Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 58145 | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 58260 | Vaginal hysterectomy, for uterus 250 g or less | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 58262 | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s) | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 58263 | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 58270 | Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 58290 | Vaginal hysterectomy, for uterus greater than 250 g | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 58291 | Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 58292 | Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 58294 | Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 58541 | Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 58542 | Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 58543 | Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g | Standard Local Prior Authorization Code List, Pg 23 Original policy |
| 58544 | Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 58545 | Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 58546 | Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 58550 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 58553 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 60660 | Percutaneous ablation of 1 or more thyroid nodule(s) | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 61215 | Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 61790 | Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); gasserian ganglion | Standard Local Prior Authorization Code List, Pg 24 Original policy |
| 61791 | Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); trigeminal medullary tract | Standard Local Prior Authorization Code List, Pg 24 Original policy |