Peach State Health Plan prior authorization, page 12

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
D2792	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2794	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2799	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2910	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2915	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2920	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2921	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2930	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2931	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2932	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2933	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2934	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2940	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2941	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2949	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2950	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2951	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2952	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2953	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2954	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2955	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2957	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2960	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2961	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2962	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2971	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2975	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2980	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D2999	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3110	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3120	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3220	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3221	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3222	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3230	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3240	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3310	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3320	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3330	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3331	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3332	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3333	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3346	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 4 Original policy
D3347	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D3348	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D3351	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D3352	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D3353	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D3354	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D3355	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy

Sources

CMS Final Rule 0057-F Prior Authorization Requirements