Anthem Blue Cross Blue Shield of Georgia policy
ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck is a public Anthem Blue Cross Blue Shield of Georgia policy (policy ANC.00008). It lists 61 CPT or HCPCS codes, 54 of them on the Anthem Blue Cross Blue Shield of Georgia prior authorization list. Not a coverage decision; the payer's own document governs.
- Policy number
- ANC.00008
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of Georgia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of Georgia policies |
|---|---|---|---|
| 00007 | Not listed | Policies naming 00007 | |
| 00008 | Not listed | Policies naming 00008 | |
| 00009 | Not listed | Policies naming 00009 | |
| 00096 | Not listed | Policies naming 00096 | |
| 15824 | On the list | Rhytidectomy; forehead | Policies naming 15824 |
| 15825 | On the list | Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) | Policies naming 15825 |
| 15826 | On the list | Rhytidectomy; glabellar frown lines | Policies naming 15826 |
| 15828 | On the list | Rhytidectomy; cheek, chin, and neck | Policies naming 15828 |
| 15829 | On the list | Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap | Policies naming 15829 |
| 15838 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad | Policies naming 15838 |
| 15840 | On the list | Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) | Policies naming 15840 |
| 15841 | On the list | Graft for facial nerve paralysis; free muscle graft (including obtaining graft) | Policies naming 15841 |
| 15842 | On the list | Graft for facial nerve paralysis; free muscle flap by microsurgical technique | Policies naming 15842 |
| 15845 | On the list | Graft for facial nerve paralysis; regional muscle transfer | Policies naming 15845 |
| 15876 | On the list | Suction assisted lipectomy; head and neck | Policies naming 15876 |
| 21083 | On the list | Impression and custom preparation; palatal lift prosthesis | Policies naming 21083 |
| 21086 | On the list | Impression and custom preparation; auricular prosthesis | Policies naming 21086 |
| 21087 | On the list | Impression and custom preparation; nasal prosthesis | Policies naming 21087 |
| 21137 | On the list | Reduction forehead; contouring only | Policies naming 21137 |
| 21138 | On the list | Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) | Policies naming 21138 |
| 21139 | On the list | Reduction forehead; contouring and setback of anterior frontal sinus wall | Policies naming 21139 |
| 21159 | On the list | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I | Policies naming 21159 |
| 21160 | On the list | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I | Policies naming 21160 |
| 21172 | On the list | Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) | Policies naming 21172 |
| 21175 | On the list | Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) | Policies naming 21175 |
| 21179 | On the list | Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) | Policies naming 21179 |
| 21180 | On the list | Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) | Policies naming 21180 |
| 21182 | On the list | Reconstruction, Orbit/Forehead/Nasoethmoid, Following Excision, Benign Tumor, Graft < 40 Sq Cm | Policies naming 21182 |
| 21183 | On the list | Reconstruction, Orbit/Forehead/Nasoethmiod, Following Excision, Benign Tumor, Graft 40-80 Sq Cm | Policies naming 21183 |
| 21184 | Not listed | Policies naming 21184 | |
| 21210 | On the list | Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) | Policies naming 21210 |
| 21230 | On the list | Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) | Policies naming 21230 |
| 21235 | On the list | Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) | Policies naming 21235 |
| 21255 | On the list | Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) | Policies naming 21255 |
| 21256 | On the list | Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia) | Policies naming 21256 |
| 21270 | On the list | Malar augmentation, prosthetic material | Policies naming 21270 |
| 21275 | On the list | Secondary Revision, Orbitocraniofacial Reconstruction | Policies naming 21275 |
| 30120 | On the list | Excision or surgical planing of skin of nose for rhinophyma | Policies naming 30120 |
| 30400 | On the list | Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip | Policies naming 30400 |
| 30410 | On the list | Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip | Policies naming 30410 |
| 30420 | On the list | Rhinoplasty, primary; including major septal repair | Policies naming 30420 |
| 30430 | On the list | Rhinoplasty, secondary; minor revision (small amount of nasal tip work) | Policies naming 30430 |
| 30435 | On the list | Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) | Policies naming 30435 |
| 30450 | On the list | Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) | Policies naming 30450 |
| 64716 | On the list | Neuroplasty and/or transposition; cranial nerve (specify) | Policies naming 64716 |
| 64732 | On the list | Transection or avulsion of; supraorbital nerve | Policies naming 64732 |
| 64734 | On the list | Transection or avulsion of; infraorbital nerve | Policies naming 64734 |
| 64736 | On the list | Transection or avulsion of; mental nerve | Policies naming 64736 |
| 64738 | On the list | Transection or avulsion of; inferior alveolar nerve by osteotomy | Policies naming 64738 |
| 64740 | On the list | Transection or avulsion of; lingual nerve | Policies naming 64740 |
| 64742 | On the list | Transection or avulsion of; facial nerve, differential or complete | Policies naming 64742 |
| 64864 | On the list | Suture of facial nerve; extracranial | Policies naming 64864 |
| 64865 | On the list | Suture of facial nerve; infratemporal, with or without grafting | Policies naming 64865 |
| 64866 | On the list | Anastomosis; facial-spinal accessory | Policies naming 64866 |
| 64868 | On the list | Anastomosis; facial-hypoglossal | Policies naming 64868 |
| 69090 | On the list | Ear piercing | Policies naming 69090 |
| 69300 | On the list | Otoplasty, protruding ear, with or without size reduction | Policies naming 69300 |
| 69399 | Not listed | Policies naming 69399 | |
| 69955 | On the list | Total facial nerve decompression and/or repair (may include graft) | Policies naming 69955 |
| L8045 | On the list | Auricular prosthesis, provided by a nonphysician | Policies naming L8045 |
| L8699 | Not listed | Policies naming L8699 |
All Anthem Blue Cross Blue Shield of Georgia policies · Anthem Blue Cross Blue Shield of Georgia prior authorization CPT list