21147 prior authorization | Anthem Blue Cross Blue Shield of Georgia

21147, 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), is on the Anthem Blue Cross Blue Shield of Georgia prior authorization list. Not a coverage or referral decision.

Code: 21147
Description: 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)
Source: Standard Local Prior Authorization Code List, Pg 96 Original policy

Anthem Blue Cross Blue Shield of Georgia prior authorization

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