Peach State Health Plan prior authorization, page 35

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
K1034	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
K1035	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
K1036	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
Q3020	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
S1040	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
S8092	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
T1502	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
T4521	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
T4522	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
T4525	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
T4529	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
T4530	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
T4531	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
T4532	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
T4533	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
T4534	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
T4535	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
T4543	DME and supplies	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
B4148	Enteral & Parenteral Therapy (Formula/Pumps)	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
B4158	Enteral & Parenteral Therapy (Formula/Pumps)	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
B4159	Enteral & Parenteral Therapy (Formula/Pumps)	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
B4160	Enteral & Parenteral Therapy (Formula/Pumps)	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
B4161	Enteral & Parenteral Therapy (Formula/Pumps)	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
B9002	Enteral & Parenteral Therapy (Formula/Pumps)	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
B9004	Enteral & Parenteral Therapy (Formula/Pumps)	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
S9432	Enteral & Parenteral Therapy (Formula/Pumps)	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1735	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1736	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1737	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1742	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1761	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1764	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1777	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1779	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1780	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1785	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1786	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1826	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1827	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1832	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1874	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1875	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1876	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1877	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1880	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1882	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1895	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1896	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1898	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy
C1899	Orthotics, Prosthetics, and OPPS Devices	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 8 Original policy

Sources

CMS Final Rule 0057-F Prior Authorization Requirements