Anthem Blue Cross Blue Shield of Georgia policy
CG-SURG-12 Penile Prosthesis Implantation
CG-SURG-12 Penile Prosthesis Implantation is a public Anthem Blue Cross Blue Shield of Georgia policy (policy CG-SURG-12). It lists 10 CPT or HCPCS codes, 9 of them on the Anthem Blue Cross Blue Shield of Georgia prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-SURG-12
- 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 |
|---|---|---|---|
| 54400 | On the list | Insertion of penile prosthesis; non-inflatable (semi- rigid) | Policies naming 54400 |
| 54401 | On the list | Insertion of penile prosthesis; inflatable (self- contained) | Policies naming 54401 |
| 54405 | On the list | Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir | Policies naming 54405 |
| 54410 | On the list | Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session | Policies naming 54410 |
| 54411 | On the list | Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue | Policies naming 54411 |
| 54416 | On the list | Removal and replacement of non-inflatable (semi- rigid) or inflatable (self-contained) penile prosthesis at the same operative session | Policies naming 54416 |
| 54417 | On the list | Removal and replacement of non-inflatable (semi- rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue | Policies naming 54417 |
| C1813 | On the list | Prosthesis, penile, inflatable | Policies naming C1813 |
| C2622 | On the list | Prosthesis, penile, noninflatable | Policies naming C2622 |
| 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