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Blue Cross and Blue Shield of Montana prior authorization, page 13

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
78458Venous Thrombosis Imaging Venogram; Bilateral2026 Commercial Medical Surgical Prior Authorization Code List, Pg 94 Original policy
78579Pulmonary Ventilation Imaging (Eg Aerosol Or Gas)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 94 Original policy
78580Pulmonary Perfusion Imaging (Eg Particulate)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 94 Original policy
78582Pulmonary Ventilation (Eg Aerosol Or Gas) And Perfusion Imaging2026 Commercial Medical Surgical Prior Authorization Code List, Pg 94 Original policy
78597Quantitative Differential Pulmonary Perfusion Including Imaging When Performed2026 Commercial Medical Surgical Prior Authorization Code List, Pg 94 Original policy
78598Quantitative Differential Pulmonary Perfusion And Ventilation (Eg Aerosol Or Gas) Including Imaging When Performed2026 Commercial Medical Surgical Prior Authorization Code List, Pg 94 Original policy
78600Brain Imaging Less Than 4 Static Views2026 Commercial Medical Surgical Prior Authorization Code List, Pg 94 Original policy
78601Brain Imaging Less Than 4 Static Views; With Vascular Flow2026 Commercial Medical Surgical Prior Authorization Code List, Pg 94 Original policy
78605Brain Imaging Minimum 4 Static Views2026 Commercial Medical Surgical Prior Authorization Code List, Pg 94 Original policy
78606Brain Imaging Minimum 4 Static Views; With Vascular Flow2026 Commercial Medical Surgical Prior Authorization Code List, Pg 94 Original policy
78608Brain Imaging Positron Emission Tomography (Pet); Metabolic Evaluation2026 Commercial Medical Surgical Prior Authorization Code List, Pg 94 Original policy
78609Brain Imaging Positron Emission Tomography (Pet); Perfusion Evaluation2026 Commercial Medical Surgical Prior Authorization Code List, Pg 94 Original policy
78610Brain Imaging Vascular Flow Only2026 Commercial Medical Surgical Prior Authorization Code List, Pg 94 Original policy
78630Cerebrospinal Fluid Flow Imaging (Not Including Introduction Of Material); Cisternography2026 Commercial Medical Surgical Prior Authorization Code List, Pg 95 Original policy
78635Cerebrospinal Fluid Flow Imaging (Not Including Introduction Of Material); Ventriculography2026 Commercial Medical Surgical Prior Authorization Code List, Pg 95 Original policy
78645Cerebrospinal Fluid Flow Imaging (Not Including Introduction Of Material); Shunt Evaluation2026 Commercial Medical Surgical Prior Authorization Code List, Pg 95 Original policy
78650Cerebrospinal Fluid Leakage Detection And Localization2026 Commercial Medical Surgical Prior Authorization Code List, Pg 95 Original policy
78660Radiopharmaceutical Dacryocystography2026 Commercial Medical Surgical Prior Authorization Code List, Pg 95 Original policy
78700Kidney Imaging Morphology2026 Commercial Medical Surgical Prior Authorization Code List, Pg 95 Original policy
78701Kidney Imaging Morphology; With Vascular Flow2026 Commercial Medical Surgical Prior Authorization Code List, Pg 95 Original policy
78707Kidney Imaging Morphology; With Vascular Flow And Function Single Study Without Pharmacological Intervention2026 Commercial Medical Surgical Prior Authorization Code List, Pg 95 Original policy
78708Kidney Imaging Morphology; With Vascular Flow And Function Single Study With Pharmacological Intervention (Eg Angiotensin Converting Enzyme Inhibitor And/Or Diuretic)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 95 Original policy
78709Kidney Imaging Morphology; With Vascular Flow And Function Multiple Studies With And Without Pharmacological Intervention (Eg Angiotensin Converting Enzyme Inhibitor And/Or Diuretic)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 96 Original policy
78725Kidney Function Study Non-Imaging Radioisotopic Study2026 Commercial Medical Surgical Prior Authorization Code List, Pg 96 Original policy
78730Urinary Bladder Residual Study (List Separately In Addition To Code For Primary Procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 96 Original policy
78740Ureteral Reflux Study (Radiopharmaceutical Voiding Cystogram)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 96 Original policy
78761Testicular Imaging With Vascular Flow2026 Commercial Medical Surgical Prior Authorization Code List, Pg 96 Original policy
78800Radiopharmaceutical Localization Of Tumor Inflammatory Process Or Distribution Of Radiopharmaceutical Agent(S) (Includes Vascular Flow And Blood Pool Imaging When Performed); Planar Single Area (Eg Head Neck Chest Pelvis) Single Day Imaging2026 Commercial Medical Surgical Prior Authorization Code List, Pg 96 Original policy
78801Radiopharmaceutical Localization Of Tumor Inflammatory Process Or Distribution Of Radiopharmaceutical Agent(S) (Includes Vascular Flow And Blood Pool Imaging When Performed); Planar 2 Or More Areas (Eg Abdomen And Pelvis Head And Chest) 1 Or More Days Imaging Or Single Area Imaging Over 2 Or More Days2026 Commercial Medical Surgical Prior Authorization Code List, Pg 97 Original policy
78802Radiopharmaceutical Localization Of Tumor Inflammatory Process Or Distribution Of Radiopharmaceutical Agent(S) (Includes Vascular Flow And Blood Pool Imaging When Performed); Planar Whole Body Single Day Imaging2026 Commercial Medical Surgical Prior Authorization Code List, Pg 97 Original policy
78803Radiopharmaceutical Localization Of Tumor Inflammatory Process Or Distribution Of Radiopharmaceutical Agent(S) (Includes Vascular Flow And Blood Pool Imaging When Performed); Tomographic (Spect) Single Area (Eg Head Neck Chest Pelvis) Or Acquisition Single Day Imaging2026 Commercial Medical Surgical Prior Authorization Code List, Pg 97 Original policy
78804Radiopharmaceutical Localization Of Tumor Inflammatory Process Or Distribution Of Radiopharmaceutical Agent(S) (Includes Vascular Flow And Blood Pool Imaging When Performed); Planar Whole Body Requiring 2 Or More Days Imaging2026 Commercial Medical Surgical Prior Authorization Code List, Pg 98 Original policy
78811Positron Emission Tomography (Pet) Imaging; Limited Area (Eg Chest Head/Neck)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 98 Original policy
78812Positron Emission Tomography (Pet) Imaging; Skull Base To Mid-Thigh2026 Commercial Medical Surgical Prior Authorization Code List, Pg 98 Original policy
78813Positron Emission Tomography (Pet) Imaging; Whole Body2026 Commercial Medical Surgical Prior Authorization Code List, Pg 98 Original policy
78814Positron Emission Tomography (Pet) With Concurrently Acquired Computed Tomography (Ct) For Attenuation Correction And Anatomical Localization Imaging; Limited Area (Eg Chest Head/Neck)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 98 Original policy
78815Positron Emission Tomography (Pet) With Concurrently Acquired Computed Tomography (Ct) For Attenuation Correction And Anatomical Localization Imaging; Skull Base To Mid-Thigh2026 Commercial Medical Surgical Prior Authorization Code List, Pg 98 Original policy
78816Positron Emission Tomography (Pet) With Concurrently Acquired Computed Tomography (Ct) For Attenuation Correction And Anatomical Localization Imaging; Whole Body2026 Commercial Medical Surgical Prior Authorization Code List, Pg 99 Original policy
78830Radiopharmaceutical Localization Of Tumor Inflammatory Process Or Distribution Of Radiopharmaceutical Agent(S) (Includes Vascular Flow And Blood Pool Imaging When Performed); Tomographic (Spect) With Concurrently Acquired Computed Tomography (Ct) Transmission Scan For Anatomical Review Localization And Determination/Detection Of Pathology Single Area (Eg Head Neck Chest Pelvis) Or Acquisition Single Day Imaging2026 Commercial Medical Surgical Prior Authorization Code List, Pg 99 Original policy
78831Radiopharmaceutical Localization Of Tumor Inflammatory Process Or Distribution Of Radiopharmaceutical Agent(S) (Includes Vascular Flow And Blood Pool Imaging When Performed); Tomographic (Spect) Minimum 2 Areas (Eg Pelvis And Knees Chest And Abdomen) Or Separate Acquisitions (Eg Lung Ventilation And Perfusion) Single Day Imaging Or Single Area Or Acquisition Over 2 Or More Days2026 Commercial Medical Surgical Prior Authorization Code List, Pg 99 Original policy
78832Radiopharmaceutical Localization Of Tumor Inflammatory Process Or Distribution Of Radiopharmaceutical Agent(S) (Includes Vascular Flow And Blood Pool Imaging When Performed); Tomographic (Spect) With Concurrently Acquired Computed Tomography (Ct) Transmission Scan For Anatomical Review Localization And Determination/Detection Of Pathology Minimum 2 Areas (Eg Pelvis And Knees Chest And Abdomen) Or Separate Acquisitions (Eg Lung Ventilation And Perfusion) Single Day Imaging Or Single Area Or Acquisition Over 2 Or More Days2026 Commercial Medical Surgical Prior Authorization Code List, Pg 100 Original policy
79101Radiopharmaceutical Therapy By Intravenous Administration2026 Commercial Medical Surgical Prior Authorization Code List, Pg 100 Original policy
79403Radiopharmaceutical Therapy Radiolabeled Monoclonal Antibody By Intravenous Infusion2026 Commercial Medical Surgical Prior Authorization Code List, Pg 100 Original policy
81120Idh1 (Isocitrate Dehydrogenase 1 [Nadp+] Soluble) (Eg Glioma) Common Variants (Eg R132H R132C)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 100 Original policy
81121Idh2 (Isocitrate Dehydrogenase 2 [Nadp+] Mitochondrial) (Eg Glioma) Common Variants (Eg R140W R172M)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 100 Original policy
81162Brca1 (Brca1 Dna Repair Associated) Brca2 (Brca2 Dna Repair Associated) (Eg Hereditary Breast And Ovarian Cancer) Gene Analysis; Full Sequence Analysis And Full Duplication/Deletion Analysis (Ie Detection Of Large Gene Rearrangements)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 101 Original policy
81163Brca1 (Brca1 Dna Repair Associated) Brca2 (Brca2 Dna Repair Associated) (Eg Hereditary Breast And Ovarian Cancer) Gene Analysis; Full Sequence Analysis2026 Commercial Medical Surgical Prior Authorization Code List, Pg 101 Original policy
81164Brca1 (Brca1 Dna Repair Associated) Brca2 (Brca2 Dna Repair Associated) (Eg Hereditary Breast And Ovarian Cancer) Gene Analysis; Full Duplication/Deletion Analysis (Ie Detection Of Large Gene Rearrangements)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 101 Original policy
81165Brca1 (Brca1 Dna Repair Associated) (Eg Hereditary Breast And Ovarian Cancer) Gene Analysis; Full Sequence Analysis2026 Commercial Medical Surgical Prior Authorization Code List, Pg 101 Original policy
81166Brca1 (Brca1 Dna Repair Associated) (Eg Hereditary Breast And Ovarian Cancer) Gene Analysis; Full Duplication/Deletion Analysis (Ie Detection Of Large Gene Rearrangements)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 101 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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