Peach State Health Plan prior authorization, page 58
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 |
|---|---|---|
| Q4377 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4378 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4379 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4380 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4381 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4382 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4383 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4384 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4385 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4386 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4387 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4388 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4389 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4390 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4391 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4392 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4393 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4394 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4395 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4396 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| Q4397 | Complex Reconstruction & Grafts (Skin Substitutes) | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 0639T | Debridement of wound, infection or burn | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 0640T | Debridement of wound, infection or burn | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 0658T | Debridement of wound, infection or burn | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 0859T | Debridement of wound, infection or burn | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 0860T | Debridement of wound, infection or burn | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 0906T | Debridement of wound, infection or burn | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 0907T | Debridement of wound, infection or burn | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 0972T | Debridement of wound, infection or burn | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 0973T | Debridement of wound, infection or burn | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 0974T | Debridement of wound, infection or burn | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 0975T | Debridement of wound, infection or burn | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 15999 | Debridement of wound, infection or burn | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 96999 | Debridement of wound, infection or burn | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 0970T | Excision of skin lesion | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 0971T | Excision of skin lesion | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 11 Original policy |
| 15734 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |
| 15769 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |
| 15771 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |
| 15772 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |
| 15773 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |
| 15774 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |
| 15775 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |
| 15776 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |
| A2001 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |
| A2002 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |
| A2003 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |
| A2004 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |
| A2005 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |
| A2006 | Skin graft | CMS Final Rule 0057-F Prior Authorization Requirements, Pg 12 Original policy |