Peach State Health Plan prior authorization, page 55
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 |
|---|---|---|
| 19357 | Breast Reconstruction and Mastectomy | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 19361 | Breast Reconstruction and Mastectomy | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 19366 | Breast Reconstruction and Mastectomy | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 19367 | Breast Reconstruction and Mastectomy | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 19368 | Breast Reconstruction and Mastectomy | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 19369 | Breast Reconstruction and Mastectomy | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 19370 | Breast Reconstruction and Mastectomy | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 19371 | Breast Reconstruction and Mastectomy | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 19380 | Breast Reconstruction and Mastectomy | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 19396 | Breast Reconstruction and Mastectomy | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 19499 | Breast Reconstruction and Mastectomy | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| C8002 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4101 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4105 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4106 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4111 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4121 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4160 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4186 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4195 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4196 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4199 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4224 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4225 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4236 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4242 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4245 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4246 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4247 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4248 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4251 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4252 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4253 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4256 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4257 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4258 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4259 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4260 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4261 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4262 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4263 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4264 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4265 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4266 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4267 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4268 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4269 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4270 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4271 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4272 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |