Policy Updates Prior AuthorizationCommercialSeptember 1, 2023

Precertification list change notification effective December 1, 2023 

This article has been updated to remove archived criteria CG-SURG-27. Please see updated article here.

The following services will be added to precertification for the effective dates listed below.

Eligibility and benefits can be verified by accessing Availity Essentials* (Availity.com) or by calling the number on the back of the member’s identification card. Service precertification is based on member’s benefit plan/eligibility at the time the service is reviewed/approved. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility and covered benefits. 

Except in the case of an emergency, failure to obtain precertification prior to rendering the designated services listed below may result in denial of reimbursement.

Add to precertification

Criteria

Criteria description

Code

Effective date

CG-SURG-27

Gender Affirming Surgery

15769

 12/01/2023

CG-SURG-88

Mastectomy for Gynecomastia

19300

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

33880

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

33881

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

33883

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

33886

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

33889

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

33891

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34701

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34702

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34703

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34704

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34706

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34710

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34712

12/01/2023

CG-SURG-78

Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies

47120

12/01/2023

CG-SURG-78

Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies

47122

12/01/2023

CG-SURG-78

Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies

47125

12/01/2023

CG-SURG-78

Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies

47130

12/01/2023

CG-SURG-27

Gender Affirming Surgery

53410

12/01/2023

CG-SURG-27

Gender Affirming Surgery

53420

12/01/2023

CG-SURG-27

Gender Affirming Surgery

53425

12/01/2023

CG-SURG-27

Gender Affirming Surgery

53430

12/01/2023

CG-SURG-27

Gender Affirming Surgery

54400

12/01/2023

CG-SURG-27

Gender Affirming Surgery

57426

12/01/2023

CG-SURG-27

Gender Affirming Surgery

58150

12/01/2023

CG-SURG-27

Gender Affirming Surgery

58571

12/01/2023

CG-SURG-27

Gender Affirming Surgery

58572

12/01/2023

CG-SURG-27

Gender Affirming Surgery

58573

12/01/2023

CG-SURG-89

Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

61790

12/01/2023

CG-SURG-89

Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

61791

12/01/2023

CG-SURG-89

Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

64600

12/01/2023

CG-SURG-89

Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

64605

12/01/2023

CG-SURG-89

Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

64610

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

75956

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

75957

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

75958

12/01/2023

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

75959

12/01/2023

CG-DME-45

Ultrasound Bone Growth Stimulation

E0760

12/01/2023

CG-DME-06

Compression Devices for Lymphedema

K1024

12/01/2023

CG-DME-06

Compression Devices for Lymphedema

K1025

12/01/2023

* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.
UM AROW #4605

Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

GABCBS-CM-034402-23-SRS33553

PUBLICATIONS: September 2023 Provider Newsletter