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Blue Cross and Blue Shield of Montana prior authorization, page 28

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
E0680Non-pneumatic compression controller with sequential calibrated gradient pressure2026 Commercial Medical Surgical Prior Authorization Code List, Pg 259 Original policy
E0739Rehabilitation system with interactive interface providing active assistance in rehabilitation therapy, includes all components and accessories, motors, microprocessors, sensors2026 Commercial Medical Surgical Prior Authorization Code List, Pg 259 Original policy
E0745Neuromuscular stimulator, electronic shock unit2026 Commercial Medical Surgical Prior Authorization Code List, Pg 259 Original policy
E0747Osteogenesis stimulator, electrical, non- invasive, other than spinal applications2026 Commercial Medical Surgical Prior Authorization Code List, Pg 259 Original policy
E0748Osteogenesis Stimulator Electrical Non- Invasive Spinal Applications2026 Commercial Medical Surgical Prior Authorization Code List, Pg 259 Original policy
E0749Osteogenesis Stimulator Electrical Surgically Implanted2026 Commercial Medical Surgical Prior Authorization Code List, Pg 259 Original policy
E0760Osteogenesis stimulator, low intensity ultrasound, non-invasive2026 Commercial Medical Surgical Prior Authorization Code List, Pg 259 Original policy
E0765Fda approved nerve stimulator, for treatment of nausea and vomiting2026 Commercial Medical Surgical Prior Authorization Code List, Pg 259 Original policy
E0766Electrical stimulation device used for cancer treatment, includes all accessories, any type2026 Commercial Medical Surgical Prior Authorization Code List, Pg 259 Original policy
E0779Amb Infusion Pump Mechanical2026 Commercial Medical Surgical Prior Authorization Code List, Pg 259 Original policy
E0780Mech Amb Infusion Pump <8Hrs2026 Commercial Medical Surgical Prior Authorization Code List, Pg 259 Original policy
E0781Ambulatory Infusion Pump Single Or Multiple Channels Electric Or Battery Operated With Administrative Equipment Worn By Patient2026 Commercial Medical Surgical Prior Authorization Code List, Pg 260 Original policy
E0782Infusion Pump Implantable Non- Programmable (Includes All Components E. G. Pump Catheter Connectors Etc. )2026 Commercial Medical Surgical Prior Authorization Code List, Pg 260 Original policy
E0783Infusion Pump System Implantable Programmable (Includes All Components E. G. Pump Catheter Connectors Etc. )2026 Commercial Medical Surgical Prior Authorization Code List, Pg 260 Original policy
E0784External Ambulatory Infusion Pump Insulin2026 Commercial Medical Surgical Prior Authorization Code List, Pg 260 Original policy
E0791Parenteral Infusion Pump Sta2026 Commercial Medical Surgical Prior Authorization Code List, Pg 260 Original policy
E1007Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction2026 Commercial Medical Surgical Prior Authorization Code List, Pg 260 Original policy
E1239Power wheelchair, pediatric size, not otherwise specified2026 Commercial Medical Surgical Prior Authorization Code List, Pg 260 Original policy
E1701Replacement cushions for jaw motion rehabilitation system, pkg. of 62026 Commercial Medical Surgical Prior Authorization Code List, Pg 260 Original policy
E1702Replacement measuring scales for jaw motion rehabilitation system, pkg. of 2002026 Commercial Medical Surgical Prior Authorization Code List, Pg 260 Original policy
E2301Wheelchair accessory, power standing system, any type2026 Commercial Medical Surgical Prior Authorization Code List, Pg 260 Original policy
E2311Power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware2026 Commercial Medical Surgical Prior Authorization Code List, Pg 261 Original policy
E2510Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access2026 Commercial Medical Surgical Prior Authorization Code List, Pg 261 Original policy
G0219Pet Imaging Whole Body; Melanoma For Non-Covered Indications2026 Commercial Medical Surgical Prior Authorization Code List, Pg 262 Original policy
G0235Pet Imaging Any Site Not Otherwise Specified2026 Commercial Medical Surgical Prior Authorization Code List, Pg 263 Original policy
G0252Pet Imaging Full And Partial-Ring Pet Scanners Only For Initial Diagnosis Of Breast Cancer And/Or Surgical Planning For Breast Cancer (E. G. Initial Staging Of Axillary Lymph Nodes)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 263 Original policy
G0277Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval2026 Commercial Medical Surgical Prior Authorization Code List, Pg 263 Original policy
G0339Image-Guided Robotic Linear Accelerator- Based Stereotactic Radiosurgery Complete Course Of Therapy In One Session Or First Session Of Fractionated Treatment2026 Commercial Medical Surgical Prior Authorization Code List, Pg 263 Original policy
G0340Image-Guided Robotic Linear Accelerator- Based Stereotactic Radiosurgery Delivery Including Collimator Changes And Custom Plugging Fractionated Treatment All Lesions Per Session Second Through Fifth Sessions Maximum Five Sessions Per Course Of Treatment2026 Commercial Medical Surgical Prior Authorization Code List, Pg 264 Original policy
G0341Percutaneous Islet Cell Transplant Includes Portal Vein Catheterization And Infusion2026 Commercial Medical Surgical Prior Authorization Code List, Pg 264 Original policy
G0342Laparoscopy For Islet Cell Transplant Includes Portal Vein Catheterization And Infusion2026 Commercial Medical Surgical Prior Authorization Code List, Pg 264 Original policy
G0343Laparotomy For Islet Cell Transplant Includes Portal Vein Catheterization And Infusion2026 Commercial Medical Surgical Prior Authorization Code List, Pg 264 Original policy
G0458Low Dose Rate (Ldr) Prostate Brachytherapy Services Composite Rate2026 Commercial Medical Surgical Prior Authorization Code List, Pg 264 Original policy
G0563Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance and real- time positron emissions-based delivery adjustments to 1 or more lesions, entire course not to exceed 5 fractions2026 Commercial Medical Surgical Prior Authorization Code List, Pg 266 Original policy
G0682Application of a premarket approval (pma), 510(k), 361 human cells, tissues or cellular and tissue-based products (hct/p) non- sheet form skin substitute for a wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, part thereof (list separately in addition to code for primary procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 266 Original policy
G6001Ultrasonic Guidance For Placement Of Radiation Therapy Fields2026 Commercial Medical Surgical Prior Authorization Code List, Pg 266 Original policy
G6002Stereoscopic X-Ray Guidance For Localization Of Target Volume For The Delivery Of Radiation Therapy2026 Commercial Medical Surgical Prior Authorization Code List, Pg 266 Original policy
G6003Radiation Treatment Delivery Single Treatment Area Single Port Or Parallel Opposed Ports Simple Blocks Or No Blocks: Up To 5Mev2026 Commercial Medical Surgical Prior Authorization Code List, Pg 266 Original policy
G6004Radiation Treatment Delivery Single Treatment Area Single Port Or Parallel Opposed Ports Simple Blocks Or No Blocks: 6-10Mev2026 Commercial Medical Surgical Prior Authorization Code List, Pg 266 Original policy
G6005Radiation Treatment Delivery Single Treatment Area Single Port Or Parallel Opposed Ports Simple Blocks Or No Blocks: 11-19Mev2026 Commercial Medical Surgical Prior Authorization Code List, Pg 267 Original policy
G6006Radiation Treatment Delivery Single Treatment Area Single Port Or Parallel Opposed Ports Simple Blocks Or No Blocks: 20Mev Or Greater2026 Commercial Medical Surgical Prior Authorization Code List, Pg 267 Original policy
G6007Radiation Treatment Delivery 2 Separate Treatment Areas 3 Or More Ports On A Single Treatment Area Use Of Multiple Blocks: Up To 5Mev2026 Commercial Medical Surgical Prior Authorization Code List, Pg 267 Original policy
G6008Radiation Treatment Delivery 2 Separate Treatment Areas 3 Or More Ports On A Single Treatment Area Use Of Multiple Blocks: 6-10Mev2026 Commercial Medical Surgical Prior Authorization Code List, Pg 267 Original policy
G6009Radiation Treatment Delivery 2 Separate Treatment Areas 3 Or More Ports On A Single Treatment Area Use Of Multiple Blocks: 11-19Mev2026 Commercial Medical Surgical Prior Authorization Code List, Pg 267 Original policy
G6010Radiation Treatment Delivery 2 Separate Treatment Areas 3 Or More Ports On A Single Treatment Area Use Of Multiple Blocks: 20 Mev Or Greater2026 Commercial Medical Surgical Prior Authorization Code List, Pg 267 Original policy
G6011Radiation Treatment Delivery 3 Or More Separate Treatment Areas Custom Blocking Tangential Ports Wedges Rotational Beam Compensators Electron Beam; Up To 5Mev2026 Commercial Medical Surgical Prior Authorization Code List, Pg 267 Original policy
G6012Radiation Treatment Delivery 3 Or More Separate Treatment Areas Custom Blocking Tangential Ports Wedges Rotational Beam Compensators Electron Beam; 6-10Mev2026 Commercial Medical Surgical Prior Authorization Code List, Pg 268 Original policy
G6013Radiation Treatment Delivery 3 Or More Separate Treatment Areas Custom Blocking Tangential Ports Wedges Rotational Beam Compensators Electron Beam; 11-19Mev2026 Commercial Medical Surgical Prior Authorization Code List, Pg 268 Original policy
G6014Radiation Treatment Delivery 3 Or More Separate Treatment Areas Custom Blocking Tangential Ports Wedges Rotational Beam Compensators Electron Beam; 20Mev Or Greater2026 Commercial Medical Surgical Prior Authorization Code List, Pg 268 Original policy
G6015Intensity Modulated Treatment Delivery Single Or Multiple Fields/Arcs Via Narrow Spatially And Temporally Modulated Beams Binary Dynamic Mlc Per Treatment Session2026 Commercial Medical Surgical Prior Authorization Code List, Pg 268 Original policy

Sources

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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.

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