Peach State Health Plan prior authorization, page 21

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
D9110	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9120	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9210	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9211	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9212	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9215	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9220	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9221	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9222	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9223	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9230	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9239	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9241	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9242	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9243	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9248	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9310	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9410	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9420	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9430	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9440	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9450	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9610	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9612	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9630	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9910	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9911	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9920	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9930	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9940	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9941	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9942	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9950	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9951	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9952	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9970	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9971	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9972	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9973	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9974	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9985	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9995	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9996	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
D9999	Oral and Dental Services	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
93503	Diagnostic cardiac catheterization, coronary arteriography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
93583	Diagnostic cardiac catheterization, coronary arteriography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
C7504	Diagnostic cardiac catheterization, coronary arteriography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
C7505	Diagnostic cardiac catheterization, coronary arteriography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
C7561	Diagnostic cardiac catheterization, coronary arteriography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy
93303	Diagnostic ultrasound of heart (echocardiogram)	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 6 Original policy

Sources

CMS Final Rule 0057-F Prior Authorization Requirements