Peach State Health Plan prior authorization, page 16

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
D6013	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6040	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6050	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6052	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6053	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6054	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6055	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6056	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6057	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6058	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6059	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6060	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6061	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6062	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6063	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6064	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6065	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6066	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6067	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6068	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6069	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6070	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6071	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6072	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6073	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6074	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6075	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6076	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6077	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6078	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6079	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6080	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6090	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6091	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6092	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6093	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6094	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6095	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6100	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6190	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6194	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6199	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6205	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6210	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6211	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6212	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6214	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6240	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6241	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6242	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