Peach State Health Plan prior authorization, page 10

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

Prior authorization codes
Code	Description	Source
D0394	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0395	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0415	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0416	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0417	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0418	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0421	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0425	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0431	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0460	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0470	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0472	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0473	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0474	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0475	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0476	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0477	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0478	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0479	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0480	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0481	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0482	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0483	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0484	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0485	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0486	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0502	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0601	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0602	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0603	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D0999	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1110	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1120	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1206	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1208	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1310	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1320	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1330	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1351	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1352	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1510	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1515	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1516	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1517	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1520	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1525	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1526	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1527	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1550	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D1555	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy

Sources

CMS Final Rule 0057-F Prior Authorization Requirements