Anthem Blue Cross Blue Shield of Georgia policy
SHBP Medical Policies & Clinical Guidelines Precertification Code List
SHBP Medical Policies & Clinical Guidelines Precertification Code List is a public Anthem Blue Cross Blue Shield of Georgia policy (effective Jan 1, 2022). It lists 2,220 CPT or HCPCS codes, 1736 of them on the Anthem Blue Cross Blue Shield of Georgia prior authorization list. Not a coverage decision; the payer's own document governs.
View the original policy (PDF) ↗
- Effective
- Jan 1, 2022
- Line of business
- Commercial
- States
- GA
- 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 |
|---|---|---|---|
| 00003 | Not listed | Policies naming 00003 | |
| 00004 | Not listed | Policies naming 00004 | |
| 00005 | Not listed | Policies naming 00005 | |
| 00007 | Not listed | Policies naming 00007 | |
| 00008 | Not listed | Policies naming 00008 | |
| 00009 | Not listed | Policies naming 00009 | |
| 00010 | Not listed | Policies naming 00010 | |
| 00011 | Not listed | Policies naming 00011 | |
| 00013 | Not listed | Policies naming 00013 | |
| 00017 | Not listed | Policies naming 00017 | |
| 00022 | Not listed | Policies naming 00022 | |
| 00023 | Not listed | Policies naming 00023 | |
| 00024 | Not listed | Policies naming 00024 | |
| 00025 | Not listed | Policies naming 00025 | |
| 00026 | Not listed | Policies naming 00026 | |
| 00027 | Not listed | Policies naming 00027 | |
| 00028 | Not listed | Policies naming 00028 | |
| 00029 | Not listed | Policies naming 00029 | |
| 00030 | Not listed | Policies naming 00030 | |
| 00031 | Not listed | Policies naming 00031 | |
| 00032 | Not listed | Policies naming 00032 | |
| 00033 | Not listed | Policies naming 00033 | |
| 00034 | Not listed | Policies naming 00034 | |
| 00035 | Not listed | Policies naming 00035 | |
| 00037 | Not listed | Policies naming 00037 | |
| 00039 | Not listed | Policies naming 00039 | |
| 00042 | Not listed | Policies naming 00042 | |
| 00047 | Not listed | Policies naming 00047 | |
| 00052 | Not listed | Policies naming 00052 | |
| 00053 | Not listed | Policies naming 00053 | |
| 00057 | Not listed | Policies naming 00057 | |
| 00059 | Not listed | Policies naming 00059 | |
| 00061 | Not listed | Policies naming 00061 | |
| 00062 | Not listed | Policies naming 00062 | |
| 00070 | Not listed | Policies naming 00070 | |
| 00071 | Not listed | Policies naming 00071 | |
| 00072 | Not listed | Policies naming 00072 | |
| 00082 | Not listed | Policies naming 00082 | |
| 00089 | Not listed | Policies naming 00089 | |
| 00090 | Not listed | Policies naming 00090 | |
| 00092 | Not listed | Policies naming 00092 | |
| 00095 | Not listed | Policies naming 00095 | |
| 00096 | Not listed | Policies naming 00096 | |
| 00098 | Not listed | Policies naming 00098 | |
| 00103 | Not listed | Policies naming 00103 | |
| 00104 | Not listed | Policies naming 00104 | |
| 00107 | Not listed | Policies naming 00107 | |
| 00111 | Not listed | Policies naming 00111 | |
| 00115 | Not listed | Policies naming 00115 | |
| 00118 | Not listed | Policies naming 00118 | |
| 00120 | Not listed | Policies naming 00120 | |
| 00121 | Not listed | Policies naming 00121 | |
| 00123 | Not listed | Policies naming 00123 | |
| 00129 | Not listed | Policies naming 00129 | |
| 00131 | Not listed | Policies naming 00131 | |
| 00141 | Not listed | Policies naming 00141 | |
| 00143 | Not listed | Policies naming 00143 | |
| 00145 | Not listed | Policies naming 00145 | |
| 00150 | Not listed | Policies naming 00150 | |
| 00158 | Not listed | Policies naming 00158 | |
| 0016U | On the list | Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation | Policies naming 0016U |
| 0017U | On the list | Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected | Policies naming 0017U |
| 0023U | On the list | Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or non-detection of FLT3 mutation and indication for or against the use of midostaurin | Policies naming 0023U |
| 0027U | On the list | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 | Policies naming 0027U |
| 0040U | On the list | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative | Policies naming 0040U |
| 0045U | On the list | Oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence score | Policies naming 0045U |
| 0046U | On the list | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative | Policies naming 0046U |
| 0049U | On the list | NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative | Policies naming 0049U |
| 00530 | Not listed | Policies naming 00530 | |
| 00534 | Not listed | Policies naming 00534 | |
| 0054T | Not listed | Policies naming 0054T | |
| 0055T | Not listed | Policies naming 0055T | |
| 00580 | On the list | Anesthesia for heart transplant or heart/lung transplant | Policies naming 00580 |
| 0071T | On the list | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue | Policies naming 0071T |
| 0072T | On the list | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue | Policies naming 0072T |
| 0075T | Not listed | Policies naming 0075T | |
| 0076T | Not listed | Policies naming 0076T | |
| 00796 | On the list | Anesthesia, Intraperitoneal Proc, Upper Abdomen, W/Laparoscopy; Liver Transplant, Recipient | Policies naming 00796 |
| 00797 | Not listed | Policies naming 00797 | |
| 00802 | Not listed | Policies naming 00802 | |
| 0095T | On the list | Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical | Policies naming 0095T |
| 0098T | On the list | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical | Policies naming 0098T |
| 0111U | On the list | Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis utilizing formalin-fixed paraffin- embedded tissue | Policies naming 0111U |
| 0153U | On the list | Oncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a triple negative breast cancer clinical subtype(s) with information on immune cell involvement | Policies naming 0153U |
| 0154U | On the list | Oncology (urothelial cancer), RNA, analysis by real- time RT-PCR of the FGFR3 (fibroblast growth factor receptor 3) gene analysis (ie, p.R248C [c.742C>T], p.S249C [c.746C>G], p.G370C [c.1108G>T], p.Y373C [c.1118A>G], FGFR3- TACC3v1, and FGFR3-TACC3v3) utilizing formalin- fixed paraffin-embedded urothelial cancer tumor tissue, reported as FGFR gene alteration status | Policies naming 0154U |
| 0155U | On the list | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha) (eg, breast cancer) gene analysis (ie, p.C420R, p.E542K, p.E545A, p.E545D [g.1635G>T only], p.E545G, p.E545K, p.Q546E, p.Q546R, p.H1047L, p.H1047R, p.H1047Y), utilizing formalin-fixed paraffin-embedded breast tumor tissue, reported as PIK3CA gene mutation status | Policies naming 0155U |
| 0163T | Not listed | Policies naming 0163T | |
| 0164T | Not listed | Policies naming 0164T | |
| 0165T | Not listed | Policies naming 0165T | |
| 0177U | On the list | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha) gene analysis of 11 gene variants utilizing plasma, reported as PIK3CA gene mutation status | Policies naming 0177U |
| 0200T | On the list | Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles | Policies naming 0200T |
| 0201T | On the list | Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles | Policies naming 0201T |
| 0202T | On the list | Posterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine | Policies naming 0202T |
| 0209U | On the list | Cytogenomic constitutional (genome-wide) analysis, interrogation of genomic regions for copy number, structural changes and areas of homozygosity for chromosomal abnormalities | Policies naming 0209U |
| 0213T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level | Policies naming 0213T |
| 0214T | On the list | njection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level | Policies naming 0214T |
| 0215T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) | Policies naming 0215T |
| 0216T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level(cid:9) | Policies naming 0216T |
| 0217T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level | Policies naming 0217T |
| 0218T | Not listed | Policies naming 0218T | |
| 0228T | Not listed | Policies naming 0228T | |
| 0229T | Not listed | Policies naming 0229T | |
| 0229U | On the list | BCAT1 (Branched chain amino acid transaminase 1) or IKZF1 (IKAROS family zinc finger 1) (eg, colorectal cancer) promoter methylation analysis | Policies naming 0229U |
| 0230T | Not listed | Policies naming 0230T | |
| 0231T | Not listed | Policies naming 0231T | |
| 0235U | On the list | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | Policies naming 0235U |
| 0253T | On the list | Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space | Policies naming 0253T |
| 0263T | On the list | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete pro | Policies naming 0263T |
| 0264T | On the list | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete pro | Policies naming 0264T |
| 0265T | On the list | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral o | Policies naming 0265T |
| 0274T | On the list | Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracic | Policies naming 0274T |
| 0275T | Not listed | Policies naming 0275T | |
| 0312T | Not listed | Policies naming 0312T | |
| 0313T | Not listed | Policies naming 0313T | |
| 0314T | Not listed | Policies naming 0314T | |
| 0315T | Not listed | Policies naming 0315T | |
| 0316T | Not listed | Policies naming 0316T | |
| 0317T | Not listed | Policies naming 0317T | |
| 0318U | On the list | Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood | Policies naming 0318U |
| 0335T | On the list | Insertion of sinus tarsi implant | Policies naming 0335T |
| 0342T | On the list | Therapeutic apheresis with selective HDL delipidation and plasma reinfusion | Policies naming 0342T |
| 0345T | On the list | Transcatheter mitral valve repair percutaneous approach via the coronary sinus | Policies naming 0345T |
| 0355T | Not listed | Policies naming 0355T | |
| 0398T | Not listed | Policies naming 0398T | |
| 0402T | On the list | Collagen cross-linking of cornea, including removal of the corneal epithelium, when performed, and intraoperative pachymetry, when performed | Policies naming 0402T |
| 0421T | Not listed | Policies naming 0421T | |
| 0424T | Not listed | Policies naming 0424T | |
| 0425T | Not listed | Policies naming 0425T | |
| 0426T | Not listed | Policies naming 0426T | |
| 0427T | Not listed | Policies naming 0427T | |
| 0428T | Not listed | Policies naming 0428T | |
| 0429T | Not listed | Policies naming 0429T | |
| 0430T | Not listed | Policies naming 0430T | |
| 0431T | Not listed | Policies naming 0431T | |
| 0432T | Not listed | Policies naming 0432T | |
| 0433T | Not listed | Policies naming 0433T | |
| 0434T | Not listed | Policies naming 0434T | |
| 0435T | Not listed | Policies naming 0435T | |
| 0436T | Not listed | Policies naming 0436T | |
| 0449T | On the list | Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device | Policies naming 0449T |
| 0450T | Not listed | Policies naming 0450T | |
| 0468T | Not listed | Policies naming 0468T | |
| 0474T | On the list | Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space | Policies naming 0474T |
| 0483T | On the list | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed | Policies naming 0483T |
| 0484T | On the list | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (eg, thoracotomy, transapical) | Policies naming 0484T |
| 0494T | On the list | Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system, including decannulation, separation from the perfusion system, and cold preservation of the allograft prior to implantation, when performed | Policies naming 0494T |
| 0495T | On the list | Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (eg, pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; first two hours in sterile field | Policies naming 0495T |
| 0496T | Not listed | Policies naming 0496T | |
| 0501T | Not listed | Policies naming 0501T | |
| 0502T | Not listed | Policies naming 0502T | |
| 0503T | Not listed | Policies naming 0503T | |
| 0504T | Not listed | Policies naming 0504T | |
| 0505T | On the list | Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion | Policies naming 0505T |
| 0510T | On the list | Removal of sinus tarsi implant | Policies naming 0510T |
| 0511T | On the list | Removal and reinsertion of sinus tarsi implant | Policies naming 0511T |
| 0524T | On the list | Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging, imaging guidance and monitoring | Policies naming 0524T |
| 0537T | Not listed | Policies naming 0537T | |
| 0538T | Not listed | Policies naming 0538T | |
| 0539T | Not listed | Policies naming 0539T | |
| 0540T | Not listed | Policies naming 0540T | |
| 0544T | On the list | Transcatheter mitral valve annulus reconstruction, with implantation of adjustable annulus reconstruction device, percutaneous approach including transseptal puncture | Policies naming 0544T |
| 0545T | On the list | Transcatheter tricuspid valve annulus reconstruction with implantation of adjustable annulus reconstruction device, percutaneous approach | Policies naming 0545T |
| 0569T | On the list | Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis | Policies naming 0569T |
| 0570T | Not listed | Policies naming 0570T | |
| 0581T | On the list | Ablation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging guidance when performed, unilateral | Policies naming 0581T |
| 0584T | On the list | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; percutaneous | Policies naming 0584T |
| 0585T | On the list | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; laparoscopic | Policies naming 0585T |
| 0586T | On the list | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; open | Policies naming 0586T |
| 0587T | Not listed | Policies naming 0587T | |
| 0588T | Not listed | Policies naming 0588T | |
| 0589T | Not listed | Policies naming 0589T | |
| 0590T | Not listed | Policies naming 0590T | |
| 0596T | On the list | Temporary female intraurethral valve-pump (ie, voiding prosthesis); initial insertion, including urethral measurement | Policies naming 0596T |
| 0597T | On the list | Temporary female intraurethral valve-pump (ie, voiding prosthesis); replacement | Policies naming 0597T |
| 0620T | On the list | Endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed | Policies naming 0620T |
| 0627T | On the list | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level [VAST, Via Disc] | Policies naming 0627T |
| 0628T | Not listed | Policies naming 0628T | |
| 0629T | On the list | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level [VAST, Via Disc] | Policies naming 0629T |
| 0630T | Not listed | Policies naming 0630T | |
| 0672T | On the list | Endovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence | Policies naming 0672T |
| 0686T | On the list | Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance | Policies naming 0686T |
| 1108G | Not listed | Policies naming 1108G | |
| 1118A | Not listed | Policies naming 1118A | |
| 11920 | On the list | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less | Policies naming 11920 |
| 11921 | On the list | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm | Policies naming 11921 |
| 11922 | Not listed | Policies naming 11922 | |
| 11950 | On the list | Subcutaneous injection of filling material (eg, collagen); 1 cc or less | Policies naming 11950 |
| 11951 | On the list | Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc | Policies naming 11951 |
| 11952 | On the list | Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc | Policies naming 11952 |
| 11954 | On the list | Subcutaneous injection of filling material (eg, collagen); over 10.0 cc | Policies naming 11954 |
| 14041 | On the list | Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm | Policies naming 14041 |
| 14060 | On the list | Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less | Policies naming 14060 |
| 14061 | On the list | Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm | Policies naming 14061 |
| 15150 | On the list | Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less | Policies naming 15150 |
| 15151 | On the list | Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) | Policies naming 15151 |
| 15152 | Not listed | Policies naming 15152 | |
| 15155 | On the list | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less | Policies naming 15155 |
| 15156 | Not listed | Policies naming 15156 | |
| 15157 | Not listed | Policies naming 15157 | |
| 15271 | On the list | Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | Policies naming 15271 |
| 15272 | Not listed | Policies naming 15272 | |
| 15273 | On the list | Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | Policies naming 15273 |
| 15274 | Not listed | Policies naming 15274 | |
| 15275 | On the list | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | Policies naming 15275 |
| 15276 | Not listed | Policies naming 15276 | |
| 15277 | On the list | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | Policies naming 15277 |
| 15278 | Not listed | Policies naming 15278 | |
| 15775 | On the list | Punch graft for hair transplant; 1 to 15 punch grafts | Policies naming 15775 |
| 15776 | On the list | Punch graft for hair transplant; more than 15 punch grafts | Policies naming 15776 |
| 15777 | Not listed | Policies naming 15777 | |
| 15780 | On the list | Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) | Policies naming 15780 |
| 15781 | On the list | Dermabrasion; segmental, face | Policies naming 15781 |
| 15782 | On the list | Dermabrasion; regional, other than face | Policies naming 15782 |
| 15783 | On the list | Dermabrasion; superficial, any site (eg, tattoo removal) | Policies naming 15783 |
| 15786 | On the list | Abrasion; single lesion (eg, keratosis, scar) | Policies naming 15786 |
| 15787 | Not listed | Policies naming 15787 | |
| 15788 | On the list | Chemical peel, facial; epidermal | Policies naming 15788 |
| 15789 | On the list | Chemical peel, facial; dermal | Policies naming 15789 |
| 15792 | On the list | Chemical peel, nonfacial; epidermal | Policies naming 15792 |
| 15793 | On the list | Chemical peel, nonfacial; dermal | Policies naming 15793 |
| 15819 | Not listed | Policies naming 15819 | |
| 15820 | On the list | Blepharoplasty, lower eyelid | Policies naming 15820 |
| 15821 | On the list | Blepharoplasty, lower eyelid; with extensive herniated fat pad | Policies naming 15821 |
| 15822 | On the list | Blepharoplasty, upper eyelid | Policies naming 15822 |
| 15823 | On the list | Blepharoplasty, upper eyelid; with excessive skin weighting down lid | Policies naming 15823 |
| 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 |
| 15830 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy | Policies naming 15830 |
| 15832 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh | Policies naming 15832 |
| 15833 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg | Policies naming 15833 |
| 15834 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip | Policies naming 15834 |
| 15835 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock | Policies naming 15835 |
| 15836 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm | Policies naming 15836 |
| 15837 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand | Policies naming 15837 |
| 15838 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad | Policies naming 15838 |
| 15839 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area | Policies naming 15839 |
| 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 |
| 15843 | Not listed | Policies naming 15843 | |
| 15844 | Not listed | Policies naming 15844 | |
| 15845 | On the list | Graft for facial nerve paralysis; regional muscle transfer | Policies naming 15845 |
| 15847 | Not listed | Policies naming 15847 | |
| 15876 | On the list | Suction assisted lipectomy; head and neck | Policies naming 15876 |
| 15877 | On the list | Suction assisted lipectomy; trunk | Policies naming 15877 |
| 15878 | On the list | Suction assisted lipectomy; upper extremity | Policies naming 15878 |
| 15879 | On the list | Suction assisted lipectomy; lower extremity | Policies naming 15879 |
| 1635G | Not listed | Policies naming 1635G | |
| 17106 | On the list | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm | Policies naming 17106 |
| 17107 | On the list | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm | Policies naming 17107 |
| 17108 | On the list | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm | Policies naming 17108 |
| 17380 | On the list | Electrolysis epilation, each 30 minutes | Policies naming 17380 |
| 17999 | On the list | Unlisted procedure, skin, mucous membrane and subcutaneous tissue | Policies naming 17999 |
| 19105 | On the list | Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma | Policies naming 19105 |
| 19316 | On the list | Mastopexy | Policies naming 19316 |
| 19318 | On the list | Breast reduction | Policies naming 19318 |
| 19325 | On the list | Breast augmentation with implant | Policies naming 19325 |
| 19328 | On the list | Removal of intact breast implant | Policies naming 19328 |
| 19330 | On the list | Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel) | Policies naming 19330 |
| 19340 | On the list | Insertion of breast implant on same day of mastectomy (ie, immediate) | Policies naming 19340 |
| 19342 | On the list | Insertion or replacement of breast implant on separate day from mastectomy | Policies naming 19342 |
| 19350 | On the list | Nipple/areola reconstruction | Policies naming 19350 |
| 19355 | On the list | Correction of inverted nipples | Policies naming 19355 |
| 19357 | On the list | Tissue expander placement in breast reconstruction, including subsequent expansion(s) | Policies naming 19357 |
| 19361 | On the list | Breast reconstruction; with latissimus dorsi flap | Policies naming 19361 |
| 19364 | On the list | Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap) | Policies naming 19364 |
| 19367 | On the list | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap | Policies naming 19367 |
| 19368 | On the list | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging) | Policies naming 19368 |
| 19369 | On the list | Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap | Policies naming 19369 |
| 19380 | On the list | Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction) | Policies naming 19380 |
| 19396 | On the list | Preparation of moulage for custom breast implant | Policies naming 19396 |
| 20605 | On the list | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance | Policies naming 20605 |
| 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 |
| 20930 | On the list | Allograft, morselized, or placement of osteopromotive material, for spine surgery only | Policies naming 20930 |
| 20931 | On the list | Allograft, structural, for spine surgery only | Policies naming 20931 |
| 20932 | On the list | Allograft, includes templating, cutting, placement and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone | Policies naming 20932 |
| 20933 | On the list | Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (ie, hemicylindrical) | Policies naming 20933 |
| 20934 | On the list | Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (ie, cylindrical) | Policies naming 20934 |
| 20936 | On the list | Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments | Policies naming 20936 |
| 20937 | On the list | Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) | Policies naming 20937 |
| 20938 | On the list | Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) | Policies naming 20938 |
| 20939 | On the list | Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision | Policies naming 20939 |
| 20974 | On the list | Electrical stimulation to aid bone healing; noninvasive (nonoperative) | Policies naming 20974 |
| 20979 | On the list | Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) | Policies naming 20979 |
| 20982 | On the list | Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency | Policies naming 20982 |
| 20983 | On the list | Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation | Policies naming 20983 |
| 20985 | Not listed | Policies naming 20985 | |
| 20999 | On the list | Unlisted procedure, musculoskeletal system, general | Policies naming 20999 |
| 21010 | On the list | Arthrotomy, temporomandibular joint | Policies naming 21010 |
| 21050 | On the list | Condylectomy, temporomandibular joint (separate procedure) | Policies naming 21050 |
| 21060 | On the list | Meniscectomy, partial or complete, temporomandibular joint (separate procedure) | Policies naming 21060 |
| 21073 | On the list | Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care) | Policies naming 21073 |
| 21083 | On the list | Impression and custom preparation; palatal lift prosthesis | Policies naming 21083 |
| 21087 | On the list | Impression and custom preparation; nasal prosthesis | Policies naming 21087 |
| 21110 | On the list | Application of interdental fixation device for conditions other than fracture or dislocation, includes removal | Policies naming 21110 |
| 21116 | On the list | Injection procedure for temporomandibular joint arthrography | Policies naming 21116 |
| 21120 | On the list | Genioplasty; augmentation (autograft, allograft, prosthetic material) | Policies naming 21120 |
And 1,920 more in the original policy.
All Anthem Blue Cross Blue Shield of Georgia policies · Anthem Blue Cross Blue Shield of Georgia prior authorization CPT list