Peach State Health Plan prior authorization, page 11

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
D1999	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2140	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2150	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2160	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2161	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2330	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2331	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2332	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2335	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2390	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2391	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2392	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2393	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2394	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2410	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2420	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2430	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2510	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2520	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2530	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2542	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2543	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2544	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2610	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2620	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2630	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2642	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2643	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2644	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2650	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2651	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2652	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2662	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2663	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2664	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2710	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2712	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2720	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2721	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2722	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2740	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2750	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2751	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2752	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2780	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2781	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2782	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2783	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2790	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2791	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