21155 prior authorization | Anthem Blue Cross Blue Shield of Georgia

21155, Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I, is on the Anthem Blue Cross Blue Shield of Georgia prior authorization list. Not a coverage or referral decision.

Code: 21155
Description: Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I
Source: Standard Local Prior Authorization Code List, Pg 96 Original policy

Anthem Blue Cross Blue Shield of Georgia prior authorization

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