Peach State Health Plan prior authorization, page 27

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
78483	Radioisotope scan, PET, and Nuclear Medicine	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
78491	Radioisotope scan, PET, and Nuclear Medicine	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
78492	Radioisotope scan, PET, and Nuclear Medicine	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
78494	Radioisotope scan, PET, and Nuclear Medicine	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
78499	Radioisotope scan, PET, and Nuclear Medicine	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
78608	Radioisotope scan, PET, and Nuclear Medicine	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
78609	Radioisotope scan, PET, and Nuclear Medicine	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
78811	Radioisotope scan, PET, and Nuclear Medicine	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
78812	Radioisotope scan, PET, and Nuclear Medicine	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
78813	Radioisotope scan, PET, and Nuclear Medicine	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
78814	Radioisotope scan, PET, and Nuclear Medicine	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
78815	Radioisotope scan, PET, and Nuclear Medicine	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
78816	Radioisotope scan, PET, and Nuclear Medicine	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
0347T	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
0348T	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
0349T	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
0350T	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
0749T	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
0750T	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
70336	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
72275	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
72285	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
76145	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
76380	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
76390	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
76497	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
76498	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
77011	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
77014	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
77078	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
77079	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
77084	Standard X-Ray and Radiography	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
0692T	Hemodialysis and Peritoneal Dialysis	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
C8000	Hemodialysis and Peritoneal Dialysis	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4100	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4210	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4239	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4311	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4313	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4314	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4316	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4322	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4326	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4327	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4328	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4330	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4331	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4332	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4333	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy
A4334	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 7 Original policy

Sources

CMS Final Rule 0057-F Prior Authorization Requirements