Peach State Health Plan prior authorization, page 17

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
D6245	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6250	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6251	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6252	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6253	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6545	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6548	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6600	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6601	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6602	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6603	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6604	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6605	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6606	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6607	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6608	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6609	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6610	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6611	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6612	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6613	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6614	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6615	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6624	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6634	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6710	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6720	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6721	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6722	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6740	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6750	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6751	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6752	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6780	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6781	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6782	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6783	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6790	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6791	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6792	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6793	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6794	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6920	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6930	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6940	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6950	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6975	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6980	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6985	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D6999	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