Peach State Health Plan prior authorization, page 14

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
D5110	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5120	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5130	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5140	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5211	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5212	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5213	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5214	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5225	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5226	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5281	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5410	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5411	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5421	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5422	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5510	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5511	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5512	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5520	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5610	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5620	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5630	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5640	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5650	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5660	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5670	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5671	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5710	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5711	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5720	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5721	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5730	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5731	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5740	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5741	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5750	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5751	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5760	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5761	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5810	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5811	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5820	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5821	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5850	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5851	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5860	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5861	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5862	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5863	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D5864	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