Peach State Health Plan prior authorization code reference, page 89

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
Code	Description	Source
63661	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
63662	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
63663	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
63664	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
63685	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
63688	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
64553	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
64555	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
64561	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
64566	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
64568	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
64575	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
64580	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
64581	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
64582	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
64590	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
64596	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
64597	Insertion of catheter or spinal stimulator	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
0198T	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
0207T	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
0687T	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
0688T	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
0704T	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
0705T	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
0706T	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92002	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92004	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92012	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92014	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92015	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92018	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92019	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92025	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92060	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92065	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92071	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92072	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92081	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92082	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92100	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92136	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92225	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92226	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92230	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92235	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92240	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92260	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92265	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92270	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy
92283	General Eye Exams & Diagnostics	CMS Final Rule 0057-F Prior Authorization Requirements, Pg 16 Original policy

Sources

CMS Final Rule 0057-F Prior Authorization Requirements