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Peach State Health Plan prior authorization code reference, page 103

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Source code lookup

Each row links an imported source code to its service or category label. Check the original document for the complete plan scope, review type and qualifications.

Source code index

Imported source codes and labels; verify the complete review requirements in the original document
CodeDescriptionSource
A0435Transportation - patient, provider, equipmentCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
A0436Transportation - patient, provider, equipmentCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
T2001Transportation - patient, provider, equipmentCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
T2002Transportation - patient, provider, equipmentCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
T2003Transportation - patient, provider, equipmentCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
T2004Transportation - patient, provider, equipmentCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
0864TDiagnostic procedures, male genital (includes minor surgery)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
54161Diagnostic procedures, male genital (includes minor surgery)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
54163Diagnostic procedures, male genital (includes minor surgery)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
54164Diagnostic procedures, male genital (includes minor surgery)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
54680Diagnostic procedures, male genital (includes minor surgery)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
54699Diagnostic procedures, male genital (includes minor surgery)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
55400Diagnostic procedures, male genital (includes minor surgery)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
55559Diagnostic procedures, male genital (includes minor surgery)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50300Kidney transplantCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50320Kidney transplantCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50323Kidney transplantCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50325Kidney transplantCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50327Kidney transplantCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50328Kidney transplantCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50329Kidney transplantCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50340Kidney transplantCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50360Kidney transplantCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50365Kidney transplantCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50370Kidney transplantCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50380Kidney transplantCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
0672TNephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
0888TNephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
0935TNephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50549Nephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50860Nephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
50949Nephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
51992Nephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
51999Nephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
53451Nephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
53452Nephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
53453Nephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
53454Nephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
54360Nephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
55970Nephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
55980Nephrectomy and Major Urinary Tract ReconstructionCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
55867Open prostatectomyCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
0872TOther diagnostic procedures of urinary tractCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
53899Other diagnostic procedures of urinary tractCMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
0738TTransurethral resection of prostate (TURP)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
0739TTransurethral resection of prostate (TURP)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
0867TTransurethral resection of prostate (TURP)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
0941TTransurethral resection of prostate (TURP)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
0942TTransurethral resection of prostate (TURP)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy
0943TTransurethral resection of prostate (TURP)CMS Final Rule 0057-F Prior Authorization Requirements, Pg 18 Original policy

Sources

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