Blue Cross and Blue Shield of Montana prior authorization, page 2
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
| Code | Description | Source |
|---|---|---|
| 20933 | Allograft Includes Templating Cutting Placement And Internal Fixation When Performed; Hemicortical Intercalary Partial (Ie Hemicylindrical) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 7 Original policy |
| 20934 | Allograft Includes Templating Cutting Placement And Internal Fixation When Performed; Intercalary Complete (Ie Cylindrical) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 7 Original policy |
| 20936 | Autograft For Spine Surgery Only (Includes Harvesting The Graft); Local (Eg Ribs Spinous Process Or Laminar Fragments) Obtained From Same Incision (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 7 Original policy |
| 20937 | Autograft For Spine Surgery Only (Includes Harvesting The Graft); Morselized (Through Separate Skin Or Fascial Incision) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 8 Original policy |
| 20938 | Autograft For Spine Surgery Only (Includes Harvesting The Graft); Structural Bicortical Or Tricortical (Through Separate Skin Or Fascial Incision) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 8 Original policy |
| 20939 | Bone Marrow Aspiration For Bone Grafting Spine Surgery Only Through Separate Skin Or Fascial Incision (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 8 Original policy |
| 20974 | Electrical Stimulation To Aid Bone Healing; Noninvasive (Nonoperative) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 8 Original policy |
| 20975 | Electrical Stimulation To Aid Bone Healing; Invasive (Operative) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 9 Original policy |
| 21085 | Impression And Custom Preparation; Oral Surgical Splint | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 9 Original policy |
| 21110 | Application Of Interdental Fixation Device For Conditions Other Than Fracture Or Dislocation Includes Removal | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 9 Original policy |
| 21125 | Augmentation Mandibular Body Or Angle; Prosthetic Material | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 9 Original policy |
| 21127 | Augmentation Mandibular Body Or Angle; With Bone Graft Onlay Or Interpositional (Includes Obtaining Autograft) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 9 Original policy |
| 21141 | Reconstruction Midface Lefort I; Single Piece Segment Movement In Any Direction (Eg For Long Face Syndrome) Without Bone Graft | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 9 Original policy |
| 21142 | Reconstruction Midface Lefort I; 2 Pieces Segment Movement In Any Direction Without Bone Graft | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 9 Original policy |
| 21143 | Reconstruction Midface Lefort I; 3 Or More Pieces Segment Movement In Any Direction Without Bone Graft | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 9 Original policy |
| 21145 | Reconstruction Midface Lefort I; Single Piece Segment Movement In Any Direction Requiring Bone Grafts (Includes Obtaining Autografts) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 10 Original policy |
| 21146 | Reconstruction Midface Lefort I; 2 Pieces Segment Movement In Any Direction Requiring Bone Grafts (Includes Obtaining Autografts) (Eg Ungrafted Unilateral Alveolar Cleft) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 10 Original policy |
| 21147 | Reconstruction Midface Lefort I; 3 Or More Pieces Segment Movement In Any Direction Requiring Bone Grafts (Includes Obtaining Autografts) (Eg Ungrafted Bilateral Alveolar Cleft Or Multiple Osteotomies) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 10 Original policy |
| 21150 | Reconstruction Midface Lefort Ii; Anterior Intrusion (Eg Treacher-Collins Syndrome) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 10 Original policy |
| 21151 | Reconstruction Midface Lefort Ii; Any Direction Requiring Bone Grafts (Includes Obtaining Autografts) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 10 Original policy |
| 21154 | Reconstruction Midface Lefort Iii (Extracranial) Any Type Requiring Bone Grafts (Includes Obtaining Autografts); Without Lefort I | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 10 Original policy |
| 21155 | Reconstruction Midface Lefort Iii (Extracranial) Any Type Requiring Bone Grafts (Includes Obtaining Autografts); With Lefort I | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 11 Original policy |
| 21159 | Reconstruction Midface Lefort Iii (Extra And Intracranial) With Forehead Advancement (Eg Mono Bloc) Requiring Bone Grafts (Includes Obtaining Autografts); Without Lefort I | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 11 Original policy |
| 21160 | Reconstruction Midface Lefort Iii (Extra And Intracranial) With Forehead Advancement (Eg Mono Bloc) Requiring Bone Grafts (Includes Obtaining Autografts); With Lefort I | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 11 Original policy |
| 21188 | Reconstruction Midface Osteotomies (Other Than Lefort Type) And Bone Grafts (Includes Obtaining Autografts) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 11 Original policy |
| 21193 | Reconstruction Of Mandibular Rami Horizontal Vertical C Or L Osteotomy; Without Bone Graft | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 11 Original policy |
| 21194 | Reconstruction Of Mandibular Rami Horizontal Vertical C Or L Osteotomy; With Bone Graft (Includes Obtaining Graft) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 11 Original policy |
| 21195 | Reconstruction Of Mandibular Rami And/Or Body Sagittal Split; Without Internal Rigid Fixation | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 11 Original policy |
| 21196 | Reconstruction Of Mandibular Rami And/Or Body Sagittal Split; With Internal Rigid Fixation | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 12 Original policy |
| 21198 | Osteotomy Mandible Segmental | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 12 Original policy |
| 21199 | Osteotomy Mandible Segmental; With Genioglossus Advancement | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 12 Original policy |
| 21206 | Osteotomy Maxilla Segmental (Eg Wassmund Or Schuchard) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 12 Original policy |
| 21208 | Osteoplasty Facial Bones; Augmentation (Autograft Allograft Or Prosthetic Implant) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 12 Original policy |
| 21209 | Osteoplasty Facial Bones; Reduction | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 12 Original policy |
| 21210 | Graft Bone; Nasal Maxillary Or Malar Areas (Includes Obtaining Graft) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 12 Original policy |
| 21215 | Graft Bone; Mandible (Includes Obtaining Graft) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 12 Original policy |
| 21230 | Graft; Rib Cartilage Autogenous To Face Chin Nose Or Ear (Includes Obtaining Graft) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 12 Original policy |
| 22206 | Osteotomy Of Spine Posterior Or Posterolateral Approach 3 Columns 1 Vertebral Segment (Eg Pedicle/Vertebral Body Subtraction); Thoracic | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 12 Original policy |
| 22207 | Osteotomy Of Spine Posterior Or Posterolateral Approach 3 Columns 1 Vertebral Segment (Eg Pedicle/Vertebral Body Subtraction); Lumbar | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 13 Original policy |
| 22208 | Osteotomy Of Spine Posterior Or Posterolateral Approach 3 Columns 1 Vertebral Segment (Eg Pedicle/Vertebral Body Subtraction); Each Additional Vertebral Segment (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 13 Original policy |
| 22210 | Osteotomy Of Spine Posterior Or Posterolateral Approach 1 Vertebral Segment; Cervical | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 13 Original policy |
| 22212 | Osteotomy Of Spine Posterior Or Posterolateral Approach 1 Vertebral Segment; Thoracic | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 13 Original policy |
| 22214 | Osteotomy Of Spine Posterior Or Posterolateral Approach 1 Vertebral Segment; Lumbar | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 13 Original policy |
| 22216 | Osteotomy Of Spine Posterior Or Posterolateral Approach 1 Vertebral Segment; Each Additional Vertebral Segment (List Separately In Addition To Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 13 Original policy |
| 22220 | Osteotomy Of Spine Including Discectomy Anterior Approach Single Vertebral Segment; Cervical | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 13 Original policy |
| 22222 | Osteotomy Of Spine Including Discectomy Anterior Approach Single Vertebral Segment; Thoracic | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 14 Original policy |
| 22224 | Osteotomy Of Spine Including Discectomy Anterior Approach Single Vertebral Segment; Lumbar | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 14 Original policy |
| 22226 | Osteotomy Of Spine Including Discectomy Anterior Approach Single Vertebral Segment; Each Additional Vertebral Segment (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 14 Original policy |
| 22510 | Percutaneous Vertebroplasty (Bone Biopsy Included When Performed) 1 Vertebral Body Unilateral Or Bilateral Injection Inclusive Of All Imaging Guidance; Cervicothoracic | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 14 Original policy |
| 22511 | Percutaneous Vertebroplasty (Bone Biopsy Included When Performed) 1 Vertebral Body Unilateral Or Bilateral Injection Inclusive Of All Imaging Guidance; Lumbosacral | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 14 Original policy |