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Blue Cross and Blue Shield of Montana prior authorization, page 29

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
G6016Compensator-Based Beam Modulation Treatment Delivery Of Inverse Planned Treatment Using 3 Or More High Resolution (Milled Or Cast) Compensator Convergent Beam Modulated Fields Per Treatment Session2026 Commercial Medical Surgical Prior Authorization Code List, Pg 268 Original policy
G6017Intra-Fraction Localization And Tracking Of Target Or Patient Motion During Delivery Of Radiation Therapy (Eg 3D Positional Tracking Gating 3D Surface Tracking) Each Fraction Of Treatment2026 Commercial Medical Surgical Prior Authorization Code List, Pg 269 Original policy
G9143Warfarin Responsiveness Testing By Genetic Technique Using Any Method Any Number Of Specimen(S)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 269 Original policy
J3145Injection, testosterone undecanoate, 1 mg2026 Commercial Medical Surgical Prior Authorization Code List, Pg 269 Original policy
K0014Other motorized/power wheelchair base2026 Commercial Medical Surgical Prior Authorization Code List, Pg 269 Original policy
K0455Infusion Pump Used For Uninterrupted Parenteral Administration Of Medication (E. G. Epoprostenol Or Treprostinol)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 269 Original policy
K0820Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 269 Original policy
K0826Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 270 Original policy
K0829Power wheelchair, group 2 extra heavy duty, captains chair, patient weight 601 pounds or more2026 Commercial Medical Surgical Prior Authorization Code List, Pg 270 Original policy
K0840Power wheelchair, group 2 extra heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more2026 Commercial Medical Surgical Prior Authorization Code List, Pg 270 Original policy
K0851Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to 450 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 270 Original policy
K0852Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 270 Original policy
K0854Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more2026 Commercial Medical Surgical Prior Authorization Code List, Pg 270 Original policy
K0855Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more2026 Commercial Medical Surgical Prior Authorization Code List, Pg 270 Original policy
K0861Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 270 Original policy
K0868Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 270 Original policy
K0869Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and including 300 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 271 Original policy
K0870Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 271 Original policy
K0871Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 271 Original policy
K0877Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 271 Original policy
K0878Power wheelchair, group 4 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 271 Original policy
K0879Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 271 Original policy
K0880Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 271 Original policy
K0885Power wheelchair, group 4 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 271 Original policy
K0886Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds2026 Commercial Medical Surgical Prior Authorization Code List, Pg 272 Original policy
L2221Addition to lower extremity orthosis, ankle system, microprocessor-controlled feature plantarflexion and/or dorsiflexion, includes power source2026 Commercial Medical Surgical Prior Authorization Code List, Pg 272 Original policy
L5610Addition to lower extremity, endoskeletal system, above knee, hydracadence system2026 Commercial Medical Surgical Prior Authorization Code List, Pg 272 Original policy
L5638Addition to lower extremity, below knee, leather socket2026 Commercial Medical Surgical Prior Authorization Code List, Pg 272 Original policy
L5639Addition to lower extremity, below knee, wood socket2026 Commercial Medical Surgical Prior Authorization Code List, Pg 272 Original policy
L5644Addition to lower extremity, above knee, wood socket2026 Commercial Medical Surgical Prior Authorization Code List, Pg 272 Original policy
L5672Addition to lower extremity, below knee, removable medial brim suspension2026 Commercial Medical Surgical Prior Authorization Code List, Pg 272 Original policy
L5712Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 272 Original policy
L5714Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control2026 Commercial Medical Surgical Prior Authorization Code List, Pg 272 Original policy
L5716Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock2026 Commercial Medical Surgical Prior Authorization Code List, Pg 272 Original policy
L5718Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control2026 Commercial Medical Surgical Prior Authorization Code List, Pg 273 Original policy
L5722Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control2026 Commercial Medical Surgical Prior Authorization Code List, Pg 273 Original policy
L5724Addition, exoskeletal knee-shin system, single axis, fluid swing phase control2026 Commercial Medical Surgical Prior Authorization Code List, Pg 273 Original policy
L5726Addition, exoskeletal knee-shin system, single axis, external joints fluid swing phase control2026 Commercial Medical Surgical Prior Authorization Code List, Pg 273 Original policy
L5728Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control2026 Commercial Medical Surgical Prior Authorization Code List, Pg 273 Original policy
L5780Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control2026 Commercial Medical Surgical Prior Authorization Code List, Pg 273 Original policy
L5795Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 273 Original policy
L5816Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock2026 Commercial Medical Surgical Prior Authorization Code List, Pg 273 Original policy
L5841Addition, endoskeletal knee-shin system, polycentric, pneumatic swing, and stance phase control2026 Commercial Medical Surgical Prior Authorization Code List, Pg 273 Original policy
L5857Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type2026 Commercial Medical Surgical Prior Authorization Code List, Pg 274 Original policy
L5858Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type2026 Commercial Medical Surgical Prior Authorization Code List, Pg 274 Original policy
L5978All lower extremity prostheses, foot, multiaxial ankle/foot2026 Commercial Medical Surgical Prior Authorization Code List, Pg 274 Original policy
L6648Upper extremity addition, shoulder lock mechanism, external powered actuator2026 Commercial Medical Surgical Prior Authorization Code List, Pg 274 Original policy
L6715Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement2026 Commercial Medical Surgical Prior Authorization Code List, Pg 274 Original policy
L6885Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power2026 Commercial Medical Surgical Prior Authorization Code List, Pg 274 Original policy
L6920Wrist disarticulation, external power, self- suspended inner socket, removable forearm shell, otto bock or equal, switch, cables, two batteries and one charger, switch control of terminal device2026 Commercial Medical Surgical Prior Authorization Code List, Pg 274 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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