Anthem Blue Cross Blue Shield of Georgia policy
SHBP Prior Authorization Code List
SHBP Prior Authorization Code List is a public Anthem Blue Cross Blue Shield of Georgia policy. It lists 1,299 CPT or HCPCS codes, 917 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) ↗
- 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 |
|---|---|---|---|
| 00002 | Not listed | Policies naming 00002 | |
| 00003 | Not listed | Policies naming 00003 | |
| 00005 | Not listed | Policies naming 00005 | |
| 00006 | Not listed | Policies naming 00006 | |
| 00007 | Not listed | Policies naming 00007 | |
| 00009 | Not listed | Policies naming 00009 | |
| 00016 | Not listed | Policies naming 00016 | |
| 00019 | Not listed | Policies naming 00019 | |
| 00022 | Not listed | Policies naming 00022 | |
| 00023 | Not listed | Policies naming 00023 | |
| 00024 | Not listed | Policies naming 00024 | |
| 00026 | Not listed | Policies naming 00026 | |
| 00028 | Not listed | Policies naming 00028 | |
| 00029 | Not listed | Policies naming 00029 | |
| 00032 | Not listed | Policies naming 00032 | |
| 00034 | Not listed | Policies naming 00034 | |
| 00037 | Not listed | Policies naming 00037 | |
| 00038 | Not listed | Policies naming 00038 | |
| 00043 | Not listed | Policies naming 00043 | |
| 00045 | Not listed | Policies naming 00045 | |
| 00052 | Not listed | Policies naming 00052 | |
| 00057 | Not listed | Policies naming 00057 | |
| 00061 | Not listed | Policies naming 00061 | |
| 00062 | Not listed | Policies naming 00062 | |
| 00067 | Not listed | Policies naming 00067 | |
| 00070 | Not listed | Policies naming 00070 | |
| 00071 | Not listed | Policies naming 00071 | |
| 00072 | Not listed | Policies naming 00072 | |
| 00073 | Not listed | Policies naming 00073 | |
| 00082 | Not listed | Policies naming 00082 | |
| 00084 | Not listed | Policies naming 00084 | |
| 00085 | Not listed | Policies naming 00085 | |
| 00090 | Not listed | Policies naming 00090 | |
| 00092 | Not listed | Policies naming 00092 | |
| 00093 | Not listed | Policies naming 00093 | |
| 00095 | Not listed | Policies naming 00095 | |
| 00096 | Not listed | Policies naming 00096 | |
| 00100 | Not listed | Policies naming 00100 | |
| 00103 | Not listed | Policies naming 00103 | |
| 00104 | Not listed | Policies naming 00104 | |
| 00105 | Not listed | Policies naming 00105 | |
| 00112 | Not listed | Policies naming 00112 | |
| 00115 | Not listed | Policies naming 00115 | |
| 00116 | Not listed | Policies naming 00116 | |
| 00123 | Not listed | Policies naming 00123 | |
| 00127 | Not listed | Policies naming 00127 | |
| 00128 | Not listed | Policies naming 00128 | |
| 00129 | Not listed | Policies naming 00129 | |
| 00139 | Not listed | Policies naming 00139 | |
| 00534 | Not listed | Policies naming 00534 | |
| 0055T | Not listed | Policies naming 0055T | |
| 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 |
| 0094U | On the list | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis | Policies naming 0094U |
| 0101T | On the list | Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy | Policies naming 0101T |
| 0101U | On the list | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with mRNA analytics to resolve variants of unknown significance when indicated (15 genes [sequencing and deletion/duplication], EPCAM and GREM1 [deletion/duplication only]) | Policies naming 0101U |
| 0102T | On the list | Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle | Policies naming 0102T |
| 0102U | On the list | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with mRNA analytics to resolve variants of unknown significance when indicated (17 genes [sequencing and deletion/duplication])(cid:9) | Policies naming 0102U |
| 0103U | On the list | Hereditary ovarian cancer (eg, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with mRNA analytics to resolve variants of unknown significance when indicated (24 genes [sequencing and deletion/duplication], EPCAM [deletion/duplication only]) | Policies naming 0103U |
| 0129U | On the list | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and deletion/duplication analysis panel (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, and TP53) | Policies naming 0129U |
| 0168U | Not listed | Policies naming 0168U | |
| 0170U | On the list | Neurology (autism spectrum disorder [ASD]), RNA, next-generation sequencing, saliva, algorithmic analysis, and results reported as predictive probability of ASD diagnosis | Policies naming 0170U |
| 0191T | Not listed | Policies naming 0191T | |
| 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 |
| 0253T | On the list | Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space | Policies naming 0253T |
| 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 | |
| 0335T | On the list | Insertion of sinus tarsi implant | Policies naming 0335T |
| 0351T | On the list | Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative | Policies naming 0351T |
| 0352T | On the list | Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; interpretation and report, real time or referred | Policies naming 0352T |
| 0353T | On the list | Optical coherence tomography of breast, surgical cavity; real time intraoperative | Policies naming 0353T |
| 0354T | On the list | Optical coherence tomography of breast, surgical cavity; interpretation and report, real time or referred | Policies naming 0354T |
| 0355T | Not listed | Policies naming 0355T | |
| 0362T | On the list | Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior. | Policies naming 0362T |
| 0373T | On the list | Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior. | Policies naming 0373T |
| 0376T | Not listed | Policies naming 0376T | |
| 0398T | Not listed | Policies naming 0398T | |
| 0421T | Not listed | Policies naming 0421T | |
| 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 | |
| 0501T | Not listed | Policies naming 0501T | |
| 0502T | Not listed | Policies naming 0502T | |
| 0503T | Not listed | Policies naming 0503T | |
| 0504T | Not listed | Policies naming 0504T | |
| 0512T | On the list | Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound | Policies naming 0512T |
| 0513T | Not listed | Policies naming 0513T | |
| 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 |
| 0546T | On the list | Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report | Policies naming 0546T |
| 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 |
| 11980 | Not listed | Policies naming 11980 | |
| 14040 | On the list | Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less | Policies naming 14040 |
| 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 |
| 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 |
| 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 |
| 15788 | On the list | Chemical peel, facial; epidermal | Policies naming 15788 |
| 15792 | On the list | Chemical peel, nonfacial; epidermal | Policies naming 15792 |
| 15793 | On the list | Chemical peel, nonfacial; dermal | Policies naming 15793 |
| 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 |
| 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 |
| 15839 | On the list | Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area | Policies naming 15839 |
| 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 |
| 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 |
| 19105 | On the list | Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma | Policies naming 19105 |
| 19294 | Not listed | Policies naming 19294 | |
| 19296 | On the list | Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy | Policies naming 19296 |
| 19297 | Not listed | Policies naming 19297 | |
| 19298 | Not listed | Policies naming 19298 | |
| 19316 | On the list | Mastopexy | Policies naming 19316 |
| 19318 | On the list | Breast reduction | Policies naming 19318 |
| 19324 | Not listed | Policies naming 19324 | |
| 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 |
| 19366 | Not listed | Policies naming 19366 | |
| 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 |
| 19499 | Not listed | Policies naming 19499 | |
| 20527 | Not listed | Policies naming 20527 | |
| 20555 | On the list | Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure) | Policies naming 20555 |
| 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 |
| 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 |
| 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 |
| 21116 | On the list | Injection procedure for temporomandibular joint arthrography | Policies naming 21116 |
| 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 |
| 21210 | On the list | Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) | Policies naming 21210 |
| 21240 | On the list | Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) | Policies naming 21240 |
| 21242 | On the list | Arthroplasty, temporomandibular joint, with allograft | Policies naming 21242 |
| 21243 | On the list | Arthroplasty, temporomandibular joint, with prosthetic joint replacement | Policies naming 21243 |
| 21685 | On the list | Hyoid myotomy and suspension | Policies naming 21685 |
| 21740 | On the list | Reconstructive repair of pectus excavatum or carinatum; open | Policies naming 21740 |
| 21742 | On the list | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy | Policies naming 21742 |
| 21743 | On the list | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy | Policies naming 21743 |
| 22214 | On the list | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar | Policies naming 22214 |
| 22224 | On the list | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar | Policies naming 22224 |
| 22505 | On the list | Manipulation of spine requiring anesthesia, any region | Policies naming 22505 |
| 22510 | On the list | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging, Guidance; cervicothoracic | Policies naming 22510 |
| 22511 | On the list | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral | Policies naming 22511 |
| 22512 | On the list | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body | Policies naming 22512 |
| 22513 | On the list | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic | Policies naming 22513 |
| 22514 | On the list | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar | Policies naming 22514 |
| 22515 | On the list | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body | Policies naming 22515 |
| 22533 | On the list | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | Policies naming 22533 |
| 22548 | Not listed | Policies naming 22548 | |
| 22551 | On the list | Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 | Policies naming 22551 |
| 22554 | On the list | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 | Policies naming 22554 |
| 22558 | On the list | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | Policies naming 22558 |
| 22590 | On the list | Arthrodesis, posterior technique, craniocervical (occiput-C2) | Policies naming 22590 |
| 22595 | On the list | Arthrodesis, posterior technique, atlas-axis (C1-C2) | Policies naming 22595 |
| 22600 | On the list | Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment | Policies naming 22600 |
| 22612 | On the list | Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) | Policies naming 22612 |
| 22630 | On the list | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar | Policies naming 22630 |
| 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 |
| 22800 | On the list | Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments | Policies naming 22800 |
| 22802 | On the list | Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments | Policies naming 22802 |
| 22804 | On the list | Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments | Policies naming 22804 |
| 22808 | On the list | Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments | Policies naming 22808 |
| 22810 | On the list | Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments | Policies naming 22810 |
| 22812 | Not listed | Policies naming 22812 | |
| 22818 | Not listed | Policies naming 22818 | |
| 22819 | Not listed | Policies naming 22819 | |
| 22830 | On the list | Exploration of spinal fusion | Policies naming 22830 |
| 22842 | On the list | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments | Policies naming 22842 |
| 22843 | On the list | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments | Policies naming 22843 |
| 22844 | On the list | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments | Policies naming 22844 |
| 22845 | On the list | Anterior instrumentation; 2 to 3 vertebral segments | Policies naming 22845 |
| 22846 | On the list | Anterior instrumentation; 4 to 7 vertebral segments | Policies naming 22846 |
| 22847 | On the list | Anterior instrumentation; 8 or more vertebral segments | Policies naming 22847 |
| 22849 | On the list | Reinsertion of spinal fixation device | Policies naming 22849 |
| 22852 | Not listed | Policies naming 22852 | |
| 22855 | Not listed | Policies naming 22855 | |
| 22856 | On the list | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical | Policies naming 22856 |
| 22857 | On the list | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); single interspace, lumbar | Policies naming 22857 |
| 22862 | On the list | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar | Policies naming 22862 |
| 22865 | On the list | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar | Policies naming 22865 |
| 23472 | On the list | Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) | Policies naming 23472 |
| 26341 | Not listed | Policies naming 26341 | |
| 27125 | On the list | Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) | Policies naming 27125 |
| 27130 | On the list | Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft | Policies naming 27130 |
| 27132 | On the list | Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft | Policies naming 27132 |
| 27134 | On the list | Revision of total hip arthroplasty; both components, with or without autograft or allograft | Policies naming 27134 |
| 27137 | On the list | Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft | Policies naming 27137 |
| 27138 | On the list | Revision of total hip arthroplasty; femoral component only, with or without allograft | Policies naming 27138 |
| 27279 | On the list | Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixation device | Policies naming 27279 |
| 27280 | On the list | Arthrodesis, sacroiliac joint, open, includes obtaining bone graft, including instrumentation, when performed | Policies naming 27280 |
| 27299 | Not listed | Policies naming 27299 | |
| 27412 | On the list | Autologous chondrocyte implantation, knee | Policies naming 27412 |
| 27415 | On the list | Osteochondral allograft, knee, open | Policies naming 27415 |
| 27416 | On the list | Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) | Policies naming 27416 |
| 27445 | Not listed | Policies naming 27445 | |
| 27447 | On the list | Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) | Policies naming 27447 |
| 27486 | On the list | Revision of total knee arthroplasty, with or without allograft; 1 component | Policies naming 27486 |
| 27487 | On the list | Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component | Policies naming 27487 |
| 27599 | On the list | Unlisted procedure, femur or knee | Policies naming 27599 |
| 28446 | On the list | Open osteochondral autograft, talus (includes obtaining graft[s]) | Policies naming 28446 |
| 28890 | On the list | Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia | Policies naming 28890 |
| 28899 | On the list | Unlisted procedure, foot or toes | Policies naming 28899 |
| 29800 | On the list | Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) | Policies naming 29800 |
| 29804 | On the list | Arthroscopy, temporomandibular joint, surgical | Policies naming 29804 |
| 29866 | On the list | Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) | Policies naming 29866 |
| 29867 | On the list | Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty) | Policies naming 29867 |
| 29868 | On the list | Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral | Policies naming 29868 |
| 29892 | On the list | Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy) | Policies naming 29892 |
| 29999 | Not listed | Policies naming 29999 | |
| 30140 | On the list | Submucous resection inferior turbinate, partial or complete, any method | Policies naming 30140 |
| 30420 | On the list | Rhinoplasty, primary; including major septal repair | Policies naming 30420 |
| 30520 | On the list | Septoplasty/Submucous Resection W/Wo Cartilage Scoring/Contouring/Graft | Policies naming 30520 |
| 30620 | On the list | Septal or other intranasal dermatoplasty (does not include obtaining graft) | Policies naming 30620 |
| 31237 | On the list | Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) | Policies naming 31237 |
| 31254 | On the list | Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior) | Policies naming 31254 |
| 31255 | On the list | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) | Policies naming 31255 |
| 31256 | On the list | Nasal/sinus endoscopy, surgical, with maxillary antrostomy | Policies naming 31256 |
| 31267 | On the list | Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus | Policies naming 31267 |
| 31276 | On the list | Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed | Policies naming 31276 |
| 31287 | On the list | Nasal/sinus endoscopy, surgical, with sphenoidotomy | Policies naming 31287 |
| 31288 | On the list | Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus | Policies naming 31288 |
| 31295 | On the list | Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa | Policies naming 31295 |
| 31296 | On the list | Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation) | Policies naming 31296 |
| 31297 | On the list | Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation) | Policies naming 31297 |
| 31643 | Not listed | Policies naming 31643 | |
| 32491 | Not listed | Policies naming 32491 | |
| 32664 | Not listed | Policies naming 32664 | |
| 32672 | Not listed | Policies naming 32672 | |
| 32701 | On the list | Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment | Policies naming 32701 |
| 32998 | On the list | Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; radiofrequency | Policies naming 32998 |
| 33202 | Not listed | Policies naming 33202 | |
| 33203 | Not listed | Policies naming 33203 | |
| 33216 | On the list | Insertion of a single transvenous electrode, permanent pacemaker or cardioverter-defibrillator | Policies naming 33216 |
| 33217 | On the list | Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverter-defibrillator | Policies naming 33217 |
| 33230 | On the list | Insertion of implantable defibrillator pulse generator only; with existing dual leads | Policies naming 33230 |
| 33231 | On the list | Insertion of implantable defibrillator pulse generator only; with existing multiple leads | Policies naming 33231 |
| 33240 | On the list | Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead | Policies naming 33240 |
| 33249 | On the list | Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber | Policies naming 33249 |
| 33270 | On the list | Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed | Policies naming 33270 |
| 33271 | On the list | Insertion of subcutaneous implantable defibrillator electrode | Policies naming 33271 |
| 33285 | On the list | Insertion, subcutaneous cardiac rhythm monitor, including programming | Policies naming 33285 |
| 33289 | On the list | Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed | Policies naming 33289 |
| 33340 | Not listed | Policies naming 33340 | |
| 33548 | Not listed | Policies naming 33548 | |
| 33999 | On the list | Unlisted procedure, cardiac surgery | Policies naming 33999 |
| 36465 | On the list | Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein) | Policies naming 36465 |
| 36466 | On the list | Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg | Policies naming 36466 |
| 36468 | On the list | Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk | Policies naming 36468 |
| 36470 | On the list | Injection of sclerosant; single incompetent vein (other than telangiectasia) | Policies naming 36470 |
| 36471 | On the list | Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg | Policies naming 36471 |
| 36473 | On the list | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated | Policies naming 36473 |
| 36474 | Not listed | Policies naming 36474 | |
| 36475 | On the list | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated | Policies naming 36475 |
| 36476 | Not listed | Policies naming 36476 | |
| 36478 | On the list | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated | Policies naming 36478 |
And 999 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