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Blue Cross and Blue Shield of Montana prior authorization, page 11

CPT code lookup

Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.

Prior authorization codes

Prior authorization codes
CodeDescriptionSource
74185Magnetic Resonance Angiography Abdomen With Or Without Contrast Material(S)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 83 Original policy
74261Computed Tomographic (Ct) Colonography Diagnostic Including Image Postprocessing; Without Contrast Material2026 Commercial Medical Surgical Prior Authorization Code List, Pg 83 Original policy
74262Computed Tomographic (Ct) Colonography Diagnostic Including Image Postprocessing; With Contrast Material(S) Including Non-Contrast Images If Performed2026 Commercial Medical Surgical Prior Authorization Code List, Pg 83 Original policy
74263Computed Tomographic (Ct) Colonography Screening Including Image Postprocessing2026 Commercial Medical Surgical Prior Authorization Code List, Pg 83 Original policy
74712Magnetic Resonance (Eg Proton) Imaging Fetal Including Placental And Maternal Pelvic Imaging When Performed; Single Or First Gestation2026 Commercial Medical Surgical Prior Authorization Code List, Pg 83 Original policy
74713Magnetic Resonance (Eg Proton) Imaging Fetal Including Placental And Maternal Pelvic Imaging When Performed; Each Additional Gestation (List Separately In Addition To Code For Primary Procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 84 Original policy
75635Computed Tomographic Angiography Abdominal Aorta And Bilateral Iliofemoral Lower Extremity Runoff With Contrast Material(S) Including Noncontrast Images If Performed And Image Postprocessing2026 Commercial Medical Surgical Prior Authorization Code List, Pg 84 Original policy
763763D Rendering With Interpretation And Reporting Of Computed Tomography Magnetic Resonance Imaging Ultrasound Or Other Tomographic Modality With Image Postprocessing Under Concurrent Supervision; Not Requiring Image Postprocessing On An Independent Workstation2026 Commercial Medical Surgical Prior Authorization Code List, Pg 84 Original policy
763773D Rendering With Interpretation And Reporting Of Computed Tomography Magnetic Resonance Imaging Ultrasound Or Other Tomographic Modality With Image Postprocessing Under Concurrent Supervision; Requiring Image Postprocessing On An Independent Workstation2026 Commercial Medical Surgical Prior Authorization Code List, Pg 84 Original policy
76380Computed Tomography Limited Or Localized Follow-Up Study2026 Commercial Medical Surgical Prior Authorization Code List, Pg 85 Original policy
76390Magnetic Resonance Spectroscopy2026 Commercial Medical Surgical Prior Authorization Code List, Pg 85 Original policy
76391Magnetic Resonance (Eg Vibration) Elastography2026 Commercial Medical Surgical Prior Authorization Code List, Pg 85 Original policy
76873Ultrasound Transrectal; Prostate Volume Study For Brachytherapy Treatment Planning (Separate Procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 85 Original policy
76965Ultrasonic Guidance For Interstitial Radioelement Application2026 Commercial Medical Surgical Prior Authorization Code List, Pg 85 Original policy
77046Magnetic Resonance Imaging Breast Without Contrast Material; Unilateral2026 Commercial Medical Surgical Prior Authorization Code List, Pg 85 Original policy
77047Magnetic Resonance Imaging Breast Without Contrast Material; Bilateral2026 Commercial Medical Surgical Prior Authorization Code List, Pg 85 Original policy
77048Magnetic Resonance Imaging Breast Without And With Contrast Material(S) Including Computer-Aided Detection (Cad Real-Time Lesion Detection Characterization And Pharmacokinetic Analysis) When Performed; Unilateral2026 Commercial Medical Surgical Prior Authorization Code List, Pg 85 Original policy
77049Magnetic Resonance Imaging Breast Without And With Contrast Material(S) Including Computer-Aided Detection (Cad Real-Time Lesion Detection Characterization And Pharmacokinetic Analysis) When Performed; Bilateral2026 Commercial Medical Surgical Prior Authorization Code List, Pg 85 Original policy
77078Computed Tomography Bone Mineral Density Study 1 Or More Sites Axial Skeleton (Eg Hips Pelvis Spine)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 86 Original policy
77084Magnetic Resonance (Eg Proton) Imaging Bone Marrow Blood Supply2026 Commercial Medical Surgical Prior Authorization Code List, Pg 86 Original policy
772953-Dimensional Radiotherapy Plan Including Dose-Volume Histograms2026 Commercial Medical Surgical Prior Authorization Code List, Pg 86 Original policy
77301Intensity Modulated Radiotherapy Plan Including Dose-Volume Histograms For Target And Critical Structure Partial Tolerance Specifications2026 Commercial Medical Surgical Prior Authorization Code List, Pg 86 Original policy
77316Brachytherapy Isodose Plan; Simple (Calculation[S] Made From 1 To 4 Sources Or Remote Afterloading Brachytherapy 1 Channel) Includes Basic Dosimetry Calculation(S)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 86 Original policy
77317Brachytherapy Isodose Plan; Intermediate (Calculation[S] Made From 5 To 10 Sources Or Remote Afterloading Brachytherapy 2- 12 Channels) Includes Basic Dosimetry Calculation(S)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 86 Original policy
77318Brachytherapy Isodose Plan; Complex (Calculation[S] Made From Over 10 Sources Or Remote Afterloading Brachytherapy Over 12 Channels) Includes Basic Dosimetry Calculation(S)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 86 Original policy
77338Multi-Leaf Collimator (Mlc) Device(S) For Intensity Modulated Radiation Therapy (Imrt) Design And Construction Per Imrt Plan2026 Commercial Medical Surgical Prior Authorization Code List, Pg 87 Original policy
77370Special Medical Radiation Physics Consultation2026 Commercial Medical Surgical Prior Authorization Code List, Pg 87 Original policy
77371Radiation Treatment Delivery Stereotactic Radiosurgery (Srs) Complete Course Of Treatment Of Cranial Lesion(S) Consisting Of 1 Session; Multi-Source Cobalt 60 Based2026 Commercial Medical Surgical Prior Authorization Code List, Pg 87 Original policy
77372Radiation Treatment Delivery Stereotactic Radiosurgery (Srs) Complete Course Of Treatment Of Cranial Lesion(S) Consisting Of 1 Session; Linear Accelerator Based2026 Commercial Medical Surgical Prior Authorization Code List, Pg 87 Original policy
77373Stereotactic Body Radiation Therapy Treatment Delivery Per Fraction To 1 Or More Lesions Including Image Guidance Entire Course Not To Exceed 5 Fractions2026 Commercial Medical Surgical Prior Authorization Code List, Pg 87 Original policy
77387Guidance For Localization Of Target Volume For Delivery Of Radiation Treatment Includes Intrafraction Tracking When Performed2026 Commercial Medical Surgical Prior Authorization Code List, Pg 88 Original policy
77402Radiation Treatment Delivery >=1 Mev; Simple2026 Commercial Medical Surgical Prior Authorization Code List, Pg 88 Original policy
77407Radiation Treatment Delivery >=1 Mev; Intermediate2026 Commercial Medical Surgical Prior Authorization Code List, Pg 88 Original policy
77412Radiation Treatment Delivery >=1 Mev; Complex2026 Commercial Medical Surgical Prior Authorization Code List, Pg 88 Original policy
77424Intraoperative Radiation Treatment Delivery X-Ray Single Treatment Session2026 Commercial Medical Surgical Prior Authorization Code List, Pg 88 Original policy
77425Intraoperative Radiation Treatment Delivery Electrons Single Treatment Session2026 Commercial Medical Surgical Prior Authorization Code List, Pg 88 Original policy
77432Stereotactic Radiation Treatment Management Of Cranial Lesion(S) (Complete Course Of Treatment Consisting Of 1 Session)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 88 Original policy
77435Stereotactic Body Radiation Therapy Treatment Management Per Treatment Course To 1 Or More Lesions Including Image Guidance Entire Course Not To Exceed 5 Fractions2026 Commercial Medical Surgical Prior Authorization Code List, Pg 88 Original policy
77436Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting2026 Commercial Medical Surgical Prior Authorization Code List, Pg 88 Original policy
77437Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting2026 Commercial Medical Surgical Prior Authorization Code List, Pg 89 Original policy
77438Surface radiation therapy; orthovoltage, delivery, >150-500 kV, per fraction2026 Commercial Medical Surgical Prior Authorization Code List, Pg 89 Original policy
77439Surface radiation therapy; superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for treatment of cutaneous tumors, per course of treatment (List separately in addition to code for primary procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 89 Original policy
77469Intraoperative Radiation Treatment Management2026 Commercial Medical Surgical Prior Authorization Code List, Pg 89 Original policy
77470Special Treatment Procedure (Eg Total Body Irradiation Hemibody Radiation Per Oral Or Endocavitary Irradiation)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 89 Original policy
77520Proton Treatment Delivery; Simple Without Compensation2026 Commercial Medical Surgical Prior Authorization Code List, Pg 89 Original policy
77522Proton Treatment Delivery; Simple With Compensation2026 Commercial Medical Surgical Prior Authorization Code List, Pg 89 Original policy
77523Proton Treatment Delivery; Intermediate2026 Commercial Medical Surgical Prior Authorization Code List, Pg 89 Original policy
77525Proton Treatment Delivery; Complex2026 Commercial Medical Surgical Prior Authorization Code List, Pg 89 Original policy
77750Infusion Or Instillation Of Radioelement Solution (Includes 3-Month Follow-Up Care)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 89 Original policy
77761Intracavitary Radiation Source Application; Simple2026 Commercial Medical Surgical Prior Authorization Code List, Pg 89 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.

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