Anthem Blue Cross Blue Shield of Georgia policy
Modifiers 59 and XE, XP, XS, and XU: Distinct Procedural Service - Professional
Modifiers 59 and XE, XP, XS, and XU: Distinct Procedural Service - Professional is a public Anthem Blue Cross Blue Shield of Georgia policy (policy C-09006, effective Mar 15, 2026). It lists 187 CPT or HCPCS codes, 62 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
- C-09006
- Effective
- Mar 15, 2026
- Line of business
- Commercial
- States
- CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, WI
- 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 |
|---|---|---|---|
| 01996 | Not listed | Policies naming 01996 | |
| 09006 | Not listed | Policies naming 09006 | |
| 15757 | Not listed | Policies naming 15757 | |
| 20527 | Not listed | Policies naming 20527 | |
| 20550 | Not listed | Policies naming 20550 | |
| 20551 | Not listed | Policies naming 20551 | |
| 20552 | Not listed | Policies naming 20552 | |
| 20553 | Not listed | Policies naming 20553 | |
| 20560 | On the list | Needle insertion(s) without injection(s); 1 or 2 muscle(s) | Policies naming 20560 |
| 20561 | On the list | Needle insertion(s) without injection(s); 3 or more muscles | Policies naming 20561 |
| 20604 | Not listed | Policies naming 20604 | |
| 20606 | On the list | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting | Policies naming 20606 |
| 20611 | Not listed | Policies naming 20611 | |
| 22554 | On the list | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 | Policies naming 22554 |
| 22585 | On the list | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace | Policies naming 22585 |
| 22612 | On the list | Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) | Policies naming 22612 |
| 22614 | On the list | Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace | Policies naming 22614 |
| 22633 | On the list | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar | Policies naming 22633 |
| 27093 | Not listed | Policies naming 27093 | |
| 27095 | Not listed | Policies naming 27095 | |
| 27275 | On the list | Manipulation, hip joint, requiring general anesthesia | Policies naming 27275 |
| 29806 | On the list | Arthroscopy, shoulder, surgical; capsulorrhaphy | Policies naming 29806 |
| 29807 | On the list | Arthroscopy, shoulder, surgical; repair of SLAP lesion | Policies naming 29807 |
| 29819 | On the list | Arthroscopy, shoulder, surgical; with removal of loose body or foreign body | Policies naming 29819 |
| 29820 | On the list | Arthroscopy, shoulder, surgical; synovectomy, partial | Policies naming 29820 |
| 29821 | On the list | Arthroscopy, shoulder, surgical; synovectomy, complete | Policies naming 29821 |
| 29822 | On the list | Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) | Policies naming 29822 |
| 29823 | On the list | Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) | Policies naming 29823 |
| 29824 | On the list | Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) | Policies naming 29824 |
| 29825 | On the list | Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation | Policies naming 29825 |
| 29827 | On the list | Arthroscopy, shoulder, surgical; with rotator cuff repair | Policies naming 29827 |
| 29834 | Not listed | Policies naming 29834 | |
| 29835 | Not listed | Policies naming 29835 | |
| 29836 | Not listed | Policies naming 29836 | |
| 29837 | Not listed | Policies naming 29837 | |
| 29838 | Not listed | Policies naming 29838 | |
| 42950 | Not listed | Policies naming 42950 | |
| 43281 | On the list | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of me | Policies naming 43281 |
| 43282 | On the list | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh | Policies naming 43282 |
| 43283 | Not listed | Policies naming 43283 | |
| 43332 | On the list | Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis | Policies naming 43332 |
| 43333 | On the list | Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis | Policies naming 43333 |
| 43644 | On the list | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) | Policies naming 43644 |
| 43645 | On the list | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption | Policies naming 43645 |
| 43770 | On the list | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) | Policies naming 43770 |
| 43771 | On the list | Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only | Policies naming 43771 |
| 43772 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only | Policies naming 43772 |
| 43773 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only | Policies naming 43773 |
| 43774 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous | Policies naming 43774 |
| 43775 | On the list | Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) | Policies naming 43775 |
| 43842 | On the list | Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty | Policies naming 43842 |
| 43843 | On the list | Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical- banded gastroplasty | Policies naming 43843 |
| 43845 | On the list | Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) | Policies naming 43845 |
| 43846 | On the list | Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy | Policies naming 43846 |
| 43847 | On the list | Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption | Policies naming 43847 |
| 43848 | On the list | Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) | Policies naming 43848 |
| 43886 | On the list | Gastric restrictive procedure, open; revision of subcutaneous port component only | Policies naming 43886 |
| 43887 | On the list | Gastric restrictive procedure, open; removal of subcutaneous port component only | Policies naming 43887 |
| 43888 | On the list | Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only | Policies naming 43888 |
| 58140 | Not listed | Policies naming 58140 | |
| 58145 | On the list | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach | Policies naming 58145 |
| 58146 | Not listed | Policies naming 58146 | |
| 58545 | On the list | Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas | Policies naming 58545 |
| 58546 | On the list | Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g | Policies naming 58546 |
| 58561 | Not listed | Policies naming 58561 | |
| 58570 | On the list | Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less | Policies naming 58570 |
| 58571 | On the list | Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less;with removal of tube(s) and/or ovary (s) | Policies naming 58571 |
| 58572 | On the list | Laparoscopy; surgical, with total hysterectomy, for uterus greater than 250 g | Policies naming 58572 |
| 58573 | On the list | Laparoscopy; surgical, with total hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary (s) | Policies naming 58573 |
| 62320 | On the list | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance | Policies naming 62320 |
| 62321 | On the list | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) | Policies naming 62321 |
| 62322 | On the list | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance | Policies naming 62322 |
| 62323 | On the list | Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) | Policies naming 62323 |
| 62324 | Not listed | Policies naming 62324 | |
| 62325 | Not listed | Policies naming 62325 | |
| 62326 | Not listed | Policies naming 62326 | |
| 62327 | Not listed | Policies naming 62327 | |
| 63081 | On the list | Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment | Policies naming 63081 |
| 63090 | On the list | Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment | Policies naming 63090 |
| 63091 | On the list | Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment | Policies naming 63091 |
| 63650 | On the list | Percutaneous implantation of neurostimulator electrode array, epidural | Policies naming 63650 |
| 63655 | On the list | Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural | Policies naming 63655 |
| 64479 | On the list | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging, Guidance (fluoroscopy or CT); cervical or thoracic, single level | Policies naming 64479 |
| 64486 | Not listed | Policies naming 64486 | |
| 64487 | Not listed | Policies naming 64487 | |
| 64488 | Not listed | Policies naming 64488 | |
| 64489 | Not listed | Policies naming 64489 | |
| 76512 | Not listed | Policies naming 76512 | |
| 76604 | Not listed | Policies naming 76604 | |
| 76700 | Not listed | Policies naming 76700 | |
| 76706 | Not listed | Policies naming 76706 | |
| 76770 | Not listed | Policies naming 76770 | |
| 76776 | Not listed | Policies naming 76776 | |
| 76815 | Not listed | Policies naming 76815 | |
| 76857 | Not listed | Policies naming 76857 | |
| 76881 | Not listed | Policies naming 76881 | |
| 76882 | Not listed | Policies naming 76882 | |
| 76942 | Not listed | Policies naming 76942 | |
| 77002 | Not listed | Policies naming 77002 | |
| 77003 | Not listed | Policies naming 77003 | |
| 77012 | Not listed | Policies naming 77012 | |
| 77021 | Not listed | Policies naming 77021 | |
| 77063 | Not listed | Policies naming 77063 | |
| 77065 | Not listed | Policies naming 77065 | |
| 77066 | Not listed | Policies naming 77066 | |
| 77427 | Not listed | Policies naming 77427 | |
| 78265 | Not listed | Policies naming 78265 | |
| 78830 | Not listed | Policies naming 78830 | |
| 78835 | Not listed | Policies naming 78835 | |
| 80305 | Not listed | Policies naming 80305 | |
| 80307 | Not listed | Policies naming 80307 | |
| 80320 | Not listed | Policies naming 80320 | |
| 80377 | Not listed | Policies naming 80377 | |
| 81000 | Not listed | Policies naming 81000 | |
| 81003 | Not listed | Policies naming 81003 | |
| 81005 | Not listed | Policies naming 81005 | |
| 82542 | On the list | Column Chromatography/Mass Spectrometry; Quantitative, Single Stationary & Mobile Phase | Policies naming 82542 |
| 82570 | Not listed | Policies naming 82570 | |
| 83516 | On the list | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitativ | Policies naming 83516 |
| 83520 | On the list | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise sp | Policies naming 83520 |
| 83789 | Not listed | Policies naming 83789 | |
| 83986 | Not listed | Policies naming 83986 | |
| 83992 | Not listed | Policies naming 83992 | |
| 84156 | Not listed | Policies naming 84156 | |
| 84311 | Not listed | Policies naming 84311 | |
| 88141 | Not listed | Policies naming 88141 | |
| 88155 | Not listed | Policies naming 88155 | |
| 88164 | Not listed | Policies naming 88164 | |
| 88167 | Not listed | Policies naming 88167 | |
| 88174 | Not listed | Policies naming 88174 | |
| 88175 | Not listed | Policies naming 88175 | |
| 91065 | Not listed | Policies naming 91065 | |
| 95700 | Not listed | Policies naming 95700 | |
| 95937 | Not listed | Policies naming 95937 | |
| 95940 | Not listed | Policies naming 95940 | |
| 95941 | Not listed | Policies naming 95941 | |
| 95950 | Not listed | Policies naming 95950 | |
| 95953 | Not listed | Policies naming 95953 | |
| 95956 | Not listed | Policies naming 95956 | |
| 95957 | Not listed | Policies naming 95957 | |
| 96365 | Not listed | Policies naming 96365 | |
| 96369 | Not listed | Policies naming 96369 | |
| 96372 | Not listed | Policies naming 96372 | |
| 96373 | Not listed | Policies naming 96373 | |
| 96374 | Not listed | Policies naming 96374 | |
| 96379 | Not listed | Policies naming 96379 | |
| 99201 | Not listed | Policies naming 99201 | |
| 99202 | Not listed | Policies naming 99202 | |
| 99211 | Not listed | Policies naming 99211 | |
| 99215 | Not listed | Policies naming 99215 | |
| 99281 | Not listed | Policies naming 99281 | |
| 99282 | Not listed | Policies naming 99282 | |
| 99283 | Not listed | Policies naming 99283 | |
| 99284 | Not listed | Policies naming 99284 | |
| 99285 | Not listed | Policies naming 99285 | |
| 99381 | Not listed | Policies naming 99381 | |
| 99397 | Not listed | Policies naming 99397 | |
| A4221 | Not listed | Policies naming A4221 | |
| A4222 | Not listed | Policies naming A4222 | |
| E0776 | Not listed | Policies naming E0776 | |
| E0781 | Not listed | Policies naming E0781 | |
| G0101 | Not listed | Policies naming G0101 | |
| G0138 | Not listed | Policies naming G0138 | |
| G0402 | Not listed | Policies naming G0402 | |
| G0438 | Not listed | Policies naming G0438 | |
| G0439 | Not listed | Policies naming G0439 | |
| G0453 | Not listed | Policies naming G0453 | |
| G0480 | Not listed | Policies naming G0480 | |
| G0481 | Not listed | Policies naming G0481 | |
| G0482 | Not listed | Policies naming G0482 | |
| G0483 | Not listed | Policies naming G0483 | |
| G0659 | Not listed | Policies naming G0659 | |
| J1202 | Not listed | Policies naming J1202 | |
| J2001 | Not listed | Policies naming J2001 | |
| L8679 | On the list | Implantable neurostimulator, pulse generator, any type | Policies naming L8679 |
| L8680 | On the list | Implantable neurostimulator electrode, each | Policies naming L8680 |
| L8687 | Not listed | Policies naming L8687 | |
| Q0091 | Not listed | Policies naming Q0091 | |
| Q3014 | Not listed | Policies naming Q3014 | |
| S0610 | Not listed | Policies naming S0610 | |
| S0612 | Not listed | Policies naming S0612 | |
| S5492 | Not listed | Policies naming S5492 | |
| S5497 | Not listed | Policies naming S5497 | |
| S9339 | Not listed | Policies naming S9339 | |
| S9349 | Not listed | Policies naming S9349 | |
| S9355 | Not listed | Policies naming S9355 | |
| S9810 | Not listed | Policies naming S9810 |
All Anthem Blue Cross Blue Shield of Georgia policies · Anthem Blue Cross Blue Shield of Georgia prior authorization CPT list