Anthem Blue Cross Blue Shield of Georgia policy
Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring is a public Anthem Blue Cross Blue Shield of Georgia policy (policy SURG.00129). It lists 23 CPT or HCPCS codes, 22 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
- SURG.00129
- 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 |
|---|---|---|---|
| 0978T | On the list | Submucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil | Policies naming 0978T |
| 0979T | On the list | Submucosal cryolysis therapy; soft palate only | Policies naming 0979T |
| 0980T | On the list | Submucosal cryolysis therapy; base of tongue and lingual tonsil only | Policies naming 0980T |
| 21141 | On the list | Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft | Policies naming 21141 |
| 21142 | On the list | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft | Policies naming 21142 |
| 21143 | On the list | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft | Policies naming 21143 |
| 21145 | On the list | Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) | Policies naming 21145 |
| 21146 | On the list | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) | Policies naming 21146 |
| 21147 | On the list | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) | Policies naming 21147 |
| 21193 | On the list | Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft | Policies naming 21193 |
| 21194 | On the list | Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) | Policies naming 21194 |
| 21195 | On the list | Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation | Policies naming 21195 |
| 21196 | On the list | Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation | Policies naming 21196 |
| 21198 | On the list | Osteotomy, mandible, segmental | Policies naming 21198 |
| 21199 | On the list | Osteotomy, mandible, segmental; with genioglossus advancement | Policies naming 21199 |
| 21206 | On the list | Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) | Policies naming 21206 |
| 21685 | On the list | Hyoid myotomy and suspension | Policies naming 21685 |
| 41512 | On the list | Tongue base suspension, permanent suture technique | Policies naming 41512 |
| 41530 | On the list | Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session | Policies naming 41530 |
| 42145 | On the list | Palatopharyngoplasty | Policies naming 42145 |
| 42299 | Not listed | Policies naming 42299 | |
| C9727 | On the list | Insertion of implants into the soft palate; minimum of 3 implants | Policies naming C9727 |
| S2080 | On the list | Laser-assisted uvulopalatoplasty (LAUP) | Policies naming S2080 |
All Anthem Blue Cross Blue Shield of Georgia policies · Anthem Blue Cross Blue Shield of Georgia prior authorization CPT list