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Blue Cross and Blue Shield of Montana prior authorization, page 26

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
A9513Lutetium Lu 177 Dotatate Therapeutic 1 Millicurie2026 Commercial Medical Surgical Prior Authorization Code List, Pg 246 Original policy
A9517Iodine I-131 sodium iodide capsule(s), therapeutic, per millicurie2026 Commercial Medical Surgical Prior Authorization Code List, Pg 246 Original policy
A9530Iodine I-131 sodium iodide solution, therapeutic, per millicurie2026 Commercial Medical Surgical Prior Authorization Code List, Pg 246 Original policy
A9543Yttrium Y-90 Ibritumomab Tiuxetan Therapeutic Per Treatment Dose Up To 40 Millicuries2026 Commercial Medical Surgical Prior Authorization Code List, Pg 246 Original policy
A9590Iodine I-131 Iobenguane 1 Millicurie2026 Commercial Medical Surgical Prior Authorization Code List, Pg 246 Original policy
A9600Strontium Sr-89 Chloride Therapeutic Per Millicurie2026 Commercial Medical Surgical Prior Authorization Code List, Pg 246 Original policy
A9602Fluorodopa F-18 Diagnostic Per Millicurie2026 Commercial Medical Surgical Prior Authorization Code List, Pg 247 Original policy
A9604Samarium Sm-153 Lexidronam Therapeutic Per Treatment Dose Up To 150 Millicuries2026 Commercial Medical Surgical Prior Authorization Code List, Pg 247 Original policy
A9606Radium Ra-223 Dichloride Therapeutic Per Microcurie2026 Commercial Medical Surgical Prior Authorization Code List, Pg 247 Original policy
A9607Lutetium Lu 177 Vipivotide Tetraxetan Therapeutic 1 Millicurie2026 Commercial Medical Surgical Prior Authorization Code List, Pg 247 Original policy
A9800Gallium Ga-68 Gozetotide Diagnostic (Locametz) 1 Millicurie2026 Commercial Medical Surgical Prior Authorization Code List, Pg 247 Original policy
B4034Enter Feed Supkit Syr By Day2026 Commercial Medical Surgical Prior Authorization Code List, Pg 247 Original policy
B4035Enteral Feed Supp Pump Per D2026 Commercial Medical Surgical Prior Authorization Code List, Pg 247 Original policy
B4036Enteral Feed Sup Kit Grav By2026 Commercial Medical Surgical Prior Authorization Code List, Pg 247 Original policy
B4102Enteral Formula For Adults Used To Replace Fluids And Electrolytes (E.G. Clear Liquids) 500 Ml = 1 Unit2026 Commercial Medical Surgical Prior Authorization Code List, Pg 247 Original policy
B4103Enteral Formula For Pediatrics Used To Replace Fluids And Electrolytes (E.G. Clear Liquids) 500 Ml = 1 Unit2026 Commercial Medical Surgical Prior Authorization Code List, Pg 247 Original policy
B4104Additive For Enteral Formula (E.G. Fiber)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 247 Original policy
B4149Enteral Formula Manufactured Blenderized Natural Foods With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Medical Surgical Prior Authorization Code List, Pg 247 Original policy
B4150Enteral Formula Nutritionally Complete With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Medical Surgical Prior Authorization Code List, Pg 248 Original policy
B4152Enteral Formula Nutritionally Complete Calorically Dense (Equal To Or Greater Than 1. 5 Kcal/Ml) With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Medical Surgical Prior Authorization Code List, Pg 248 Original policy
B4153Enteral Formula Nutritionally Complete Hydrolyzed Proteins (Amino Acids And Peptide Chain) Includes Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Medical Surgical Prior Authorization Code List, Pg 248 Original policy
B4154Enteral Formula Nutritionally Complete For Special Metabolic Needs Excludes Inherited Disease Of Metabolism Includes Altered Composition Of Proteins Fats Carbohydrates Vitamins And/Or Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Medical Surgical Prior Authorization Code List, Pg 248 Original policy
B4155Enteral Formula Nutritionally Incomplete/Modular Nutrients Includes Specific Nutrients Carbohydrates (E. G. Glucose Polymers) Proteins/Amino Acids (E. G. Glutamine Arginine) Fat (E. G. Medium Chain Triglycerides) Or Combination Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Medical Surgical Prior Authorization Code List, Pg 249 Original policy
B4158Enteral Formula For Pediatrics Nutritionally Complete With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber And/Or Iron Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Medical Surgical Prior Authorization Code List, Pg 249 Original policy
B4159Enteral Formula For Pediatrics Nutritionally Complete Soy Based With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber And/Or Iron Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Medical Surgical Prior Authorization Code List, Pg 249 Original policy
B4160Enteral Formula For Pediatrics Nutritionally Complete Calorically Dense (Equal To Or Greater Than 0.7 Kcal/Ml) With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Medical Surgical Prior Authorization Code List, Pg 250 Original policy
B4161Enteral Formula For Pediatrics Hydrolyzed/Amino Acids And Peptide Chain Proteins Includes Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Medical Surgical Prior Authorization Code List, Pg 250 Original policy
B4164Parenteral Nutrition Solution: Carbohydrates (Dextrose) 50% Or Less (500 Ml = 1 Unit) - Homemix2026 Commercial Medical Surgical Prior Authorization Code List, Pg 250 Original policy
B4168Parenteral Nutrition Solution; Amino Acid 3. 5% (500 Ml = 1 Unit) - Homemix2026 Commercial Medical Surgical Prior Authorization Code List, Pg 250 Original policy
B4172Parenteral Nutrition Solution; Amino Acid 5. 5% Through 7% (500 Ml = 1 Unit) - Homemix2026 Commercial Medical Surgical Prior Authorization Code List, Pg 250 Original policy
B4176Parenteral Nutrition Solution; Amino Acid 7% Through 8. 5% (500 Ml = 1 Unit) - Homemix2026 Commercial Medical Surgical Prior Authorization Code List, Pg 250 Original policy
B4178Parenteral Nutrition Solution: Amino Acid Greater Than 8. 5% (500 Ml = 1 Unit) - Homemix2026 Commercial Medical Surgical Prior Authorization Code List, Pg 250 Original policy
B4180Parenteral Nutrition Solution; Carbohydrates (Dextrose) Greater Than 50% (500 Ml=1 Unit) - Homemix2026 Commercial Medical Surgical Prior Authorization Code List, Pg 251 Original policy
B4185Parenteral Nutrition Solution Not Otherwise Specified 10 Grams Lipids2026 Commercial Medical Surgical Prior Authorization Code List, Pg 251 Original policy
B4189Parenteral Nutrition Solution; Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength 10 To 51 Grams Of Protein - Premix2026 Commercial Medical Surgical Prior Authorization Code List, Pg 251 Original policy
B4193Parenteral Nutrition Solution; Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength 52 To 73 Grams Of Protein - Premix2026 Commercial Medical Surgical Prior Authorization Code List, Pg 251 Original policy
B4197Parenteral Nutrition Solution; Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength 74 To 100 Grams Of Protein - Premix2026 Commercial Medical Surgical Prior Authorization Code List, Pg 251 Original policy
B4199Parenteral Nutrition Solution; Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength Over 100 Grams Of Protein - Premix2026 Commercial Medical Surgical Prior Authorization Code List, Pg 251 Original policy
B4216Parenteral Nutrition; Additives (Vitamins Trace Elements Heparin Electrolytes) Homemix Per Day2026 Commercial Medical Surgical Prior Authorization Code List, Pg 252 Original policy
B4220Parenteral Nutrition Supply Kit; Premix Per Day2026 Commercial Medical Surgical Prior Authorization Code List, Pg 252 Original policy
B4222Parenteral Nutrition Supply Kit; Home Mix Per Day2026 Commercial Medical Surgical Prior Authorization Code List, Pg 252 Original policy
B4224Parenteral Nutrition Administration Kit Per Day2026 Commercial Medical Surgical Prior Authorization Code List, Pg 252 Original policy
B5000Parenteral Nutrition Solution Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength Renal- Aminosyn-Rf Nephramine Renamine- Premix2026 Commercial Medical Surgical Prior Authorization Code List, Pg 252 Original policy
B5100Parenteral Nutrition Solution Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength Hepatic Hepatamine-Premix2026 Commercial Medical Surgical Prior Authorization Code List, Pg 252 Original policy
B5200Parenteral Nutrition Solution Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength Stress- Branch Chain Amino Acids-Freamine-Hbc- Premix2026 Commercial Medical Surgical Prior Authorization Code List, Pg 252 Original policy
B9002Enteral Nutrition Infusion Pump Any Type2026 Commercial Medical Surgical Prior Authorization Code List, Pg 253 Original policy
B9004Parenteral Nutrition Infusion Pump Portable2026 Commercial Medical Surgical Prior Authorization Code List, Pg 253 Original policy
B9006Parenteral Nutrition Infusion Pump Stationary2026 Commercial Medical Surgical Prior Authorization Code List, Pg 253 Original policy
B9998Noc For Enteral Supplies2026 Commercial Medical Surgical Prior Authorization Code List, Pg 253 Original policy
B9999Noc For Parenteral Supplies2026 Commercial Medical Surgical Prior Authorization Code List, Pg 253 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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