Peach State Health Plan prior authorization, page 2
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
| Code | Description | Source |
|---|---|---|
| 64630 | Interventional Pain Management (Nerve Blocks) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 64632 | Interventional Pain Management (Nerve Blocks) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 64633 | Interventional Pain Management (Nerve Blocks) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 64635 | Interventional Pain Management (Nerve Blocks) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 64640 | Interventional Pain Management (Nerve Blocks) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 64650 | Interventional Pain Management (Nerve Blocks) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 64653 | Interventional Pain Management (Nerve Blocks) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 64680 | Interventional Pain Management (Nerve Blocks) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 64681 | Interventional Pain Management (Nerve Blocks) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| G0260 | Interventional Pain Management (Nerve Blocks) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| G0465 | Interventional Pain Management (Nerve Blocks) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 0362T | Applied Behavior Analysis (ABA) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 0373T | Applied Behavior Analysis (ABA) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 97151 | Applied Behavior Analysis (ABA) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 97152 | Applied Behavior Analysis (ABA) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 97153 | Applied Behavior Analysis (ABA) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 97154 | Applied Behavior Analysis (ABA) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 97155 | Applied Behavior Analysis (ABA) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 97156 | Applied Behavior Analysis (ABA) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 97157 | Applied Behavior Analysis (ABA) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 97158 | Applied Behavior Analysis (ABA) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| A9291 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| A9292 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| G0552 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H0004 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H0014 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H0015 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H0017 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H0018 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H0031 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H0032 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H0036 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H0039 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H0045 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H2013 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H2014 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H2015 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H2016 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H2017 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H2022 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H2025 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H2038 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H2040 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| H2041 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| T1016 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| T1040 | Behavioral Health Management, Treatment, and Rehab | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 96105 | Neuropsychological and Psychological Testing | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 96116 | Neuropsychological and Psychological Testing | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 96121 | Neuropsychological and Psychological Testing | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |
| 96130 | Neuropsychological and Psychological Testing | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 3 Original policy |