Peach State Health Plan prior authorization, page 18

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
D7111	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7140	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7210	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7220	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7230	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7240	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7241	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7250	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7251	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7260	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7261	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7270	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7272	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7280	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7282	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7283	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7285	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7286	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7287	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7288	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7290	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7291	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7292	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7293	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7294	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7295	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7310	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7311	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7320	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7321	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7340	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7350	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7410	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7411	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7412	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7413	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7414	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7415	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7440	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7441	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7450	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7451	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7460	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7461	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7465	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7471	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7472	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7473	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7485	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 5 Original policy
D7490	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