Blue Cross and Blue Shield of Montana prior authorization, page 3
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 |
|---|---|---|
| 22512 | Percutaneous Vertebroplasty (Bone Biopsy Included When Performed) 1 Vertebral Body Unilateral Or Bilateral Injection Inclusive Of All Imaging Guidance; Each Additional Cervicothoracic Or Lumbosacral Vertebral Body (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 14 Original policy |
| 22513 | Percutaneous Vertebral Augmentation Including Cavity Creation (Fracture Reduction And Bone Biopsy Included When Performed) Using Mechanical Device (Eg Kyphoplasty) 1 Vertebral Body Unilateral Or Bilateral Cannulation Inclusive Of All Imaging Guidance; Thoracic | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 15 Original policy |
| 22514 | Percutaneous Vertebral Augmentation Including Cavity Creation (Fracture Reduction And Bone Biopsy Included When Performed) Using Mechanical Device (Eg Kyphoplasty) 1 Vertebral Body Unilateral Or Bilateral Cannulation Inclusive Of All Imaging Guidance; Lumbar | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 15 Original policy |
| 22515 | Percutaneous Vertebral Augmentation Including Cavity Creation (Fracture Reduction And Bone Biopsy Included When Performed) Using Mechanical Device (Eg Kyphoplasty) 1 Vertebral Body Unilateral Or Bilateral Cannulation Inclusive Of All Imaging Guidance; Each Additional Thoracic Or Lumbar Vertebral Body (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 15 Original policy |
| 22532 | Arthrodesis Lateral Extracavitary Technique Including Minimal Discectomy To Prepare Interspace (Other Than For Decompression); Thoracic | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 16 Original policy |
| 22533 | Arthrodesis Lateral Extracavitary Technique Including Minimal Discectomy To Prepare Interspace (Other Than For Decompression); Lumbar | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 16 Original policy |
| 22534 | Arthrodesis Lateral Extracavitary Technique Including Minimal Discectomy To Prepare Interspace (Other Than For Decompression); Thoracic Or Lumbar Each Additional Vertebral Segment (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 16 Original policy |
| 22548 | Arthrodesis Anterior Transoral Or Extraoral Technique Clivus-C1-C2 (Atlas-Axis) With Or Without Excision Of Odontoid Process | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 17 Original policy |
| 22551 | Arthrodesis Anterior Interbody Including Disc Space Preparation Discectomy Osteophytectomy And Decompression Of Spinal Cord And/Or Nerve Roots; Cervical Below C2 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 17 Original policy |
| 22552 | Arthrodesis Anterior Interbody Including Disc Space Preparation Discectomy Osteophytectomy And Decompression Of Spinal Cord And/Or Nerve Roots; Cervical Below C2 Each Additional Interspace (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 17 Original policy |
| 22554 | Arthrodesis Anterior Interbody Technique Including Minimal Discectomy To Prepare Interspace (Other Than For Decompression); Cervical Below C2 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 17 Original policy |
| 22556 | Arthrodesis Anterior Interbody Technique Including Minimal Discectomy To Prepare Interspace (Other Than For Decompression); Thoracic | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 17 Original policy |
| 22558 | Arthrodesis Anterior Interbody Technique Including Minimal Discectomy To Prepare Interspace (Other Than For Decompression); Lumbar | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 18 Original policy |
| 22585 | Arthrodesis Anterior Interbody Technique Including Minimal Discectomy To Prepare Interspace (Other Than For Decompression); Each Additional Interspace (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 18 Original policy |
| 22590 | Arthrodesis Posterior Technique Craniocervical (Occiput-C2) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 18 Original policy |
| 22595 | Arthrodesis Posterior Technique Atlas-Axis (C1-C2) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 18 Original policy |
| 22600 | Arthrodesis Posterior Or Posterolateral Technique Single Interspace; Cervical Below C2 Segment | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 18 Original policy |
| 22610 | Arthrodesis Posterior Or Posterolateral Technique Single Interspace; Thoracic (With Lateral Transverse Technique When Performed) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 19 Original policy |
| 22612 | Arthrodesis Posterior Or Posterolateral Technique Single Interspace; Lumbar (With Lateral Transverse Technique When Performed) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 19 Original policy |
| 22614 | Arthrodesis Posterior Or Posterolateral Technique Single Interspace; Each Additional Interspace (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 19 Original policy |
| 22630 | Arthrodesis Posterior Interbody Technique Including Laminectomy And/Or Discectomy To Prepare Interspace (Other Than For Decompression) Single Interspace Lumbar | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 19 Original policy |
| 22632 | Arthrodesis Posterior Interbody Technique Including Laminectomy And/Or Discectomy To Prepare Interspace (Other Than For Decompression) Single Interspace Lumbar; Each Additional Interspace (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 20 Original policy |
| 22633 | Arthrodesis Combined Posterior Or Posterolateral Technique With Posterior Interbody Technique Including Laminectomy And/Or Discectomy Sufficient To Prepare Interspace (Other Than For Decompression) Single Interspace Lumbar | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 20 Original policy |
| 22634 | Arthrodesis Combined Posterior Or Posterolateral Technique With Posterior Interbody Technique Including Laminectomy And/Or Discectomy Sufficient To Prepare Interspace (Other Than For Decompression) Single Interspace Lumbar; Each Additional Interspace (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 21 Original policy |
| 22800 | Arthrodesis Posterior For Spinal Deformity With Or Without Cast; Up To 6 Vertebral Segments | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 21 Original policy |
| 22802 | Arthrodesis Posterior For Spinal Deformity With Or Without Cast; 7 To 12 Vertebral Segments | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 22 Original policy |
| 22804 | Arthrodesis Posterior For Spinal Deformity With Or Without Cast; 13 Or More Vertebral Segments | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 22 Original policy |
| 22808 | Arthrodesis Anterior For Spinal Deformity With Or Without Cast; 2 To 3 Vertebral Segments | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 22 Original policy |
| 22810 | Arthrodesis Anterior For Spinal Deformity With Or Without Cast; 4 To 7 Vertebral Segments | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 22 Original policy |
| 22812 | Arthrodesis Anterior For Spinal Deformity With Or Without Cast; 8 Or More Vertebral Segments | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 23 Original policy |
| 22818 | Kyphectomy Circumferential Exposure Of Spine And Resection Of Vertebral Segment(S) (Including Body And Posterior Elements); Single Or 2 Segments | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 23 Original policy |
| 22819 | Kyphectomy Circumferential Exposure Of Spine And Resection Of Vertebral Segment(S) (Including Body And Posterior Elements); 3 Or More Segments | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 23 Original policy |
| 22830 | Exploration Of Spinal Fusion | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 23 Original policy |
| 22840 | Posterior Non-Segmental Instrumentation (Eg Harrington Rod Technique Pedicle Fixation Across 1 Interspace Atlantoaxial Transarticular Screw Fixation Sublaminar Wiring At C1 Facet Screw Fixation) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 23 Original policy |
| 22841 | Internal Spinal Fixation By Wiring Of Spinous Processes (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 24 Original policy |
| 22842 | Posterior Segmental Instrumentation (Eg Pedicle Fixation Dual Rods With Multiple Hooks And Sublaminar Wires); 3 To 6 Vertebral Segments (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 24 Original policy |
| 22843 | Posterior Segmental Instrumentation (Eg Pedicle Fixation Dual Rods With Multiple Hooks And Sublaminar Wires); 7 To 12 Vertebral Segments (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 24 Original policy |
| 22844 | Posterior Segmental Instrumentation (Eg Pedicle Fixation Dual Rods With Multiple Hooks And Sublaminar Wires); 13 Or More Vertebral Segments (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 25 Original policy |
| 22845 | Anterior Instrumentation; 2 To 3 Vertebral Segments (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 25 Original policy |
| 22846 | Anterior Instrumentation; 4 To 7 Vertebral Segments (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 25 Original policy |
| 22847 | Anterior Instrumentation; 8 Or More Vertebral Segments (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 26 Original policy |
| 22848 | Pelvic Fixation (Attachment Of Caudal End Of Instrumentation To Pelvic Bony Structures) Other Than Sacrum (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 26 Original policy |
| 22849 | Reinsertion Of Spinal Fixation Device | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 26 Original policy |
| 22853 | Insertion Of Interbody Biomechanical Device(S) (Eg Synthetic Cage Mesh) With Integral Anterior Instrumentation For Device Anchoring (Eg Screws Flanges) When Performed To Intervertebral Disc Space In Conjunction With Interbody Arthrodesis Each Interspace (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 26 Original policy |
| 22854 | Insertion Of Intervertebral Biomechanical Device(S) (Eg Synthetic Cage Mesh) With Integral Anterior Instrumentation For Device Anchoring (Eg Screws Flanges) When Performed To Vertebral Corpectomy(Ies) (Vertebral Body Resection Partial Or Complete) Defect In Conjunction With Interbody Arthrodesis Each Contiguous Defect (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 27 Original policy |
| 22856 | Total Disc Arthroplasty (Artificial Disc) Anterior Approach Including Discectomy With End Plate Preparation (Includes Osteophytectomy For Nerve Root Or Spinal Cord Decompression And Microdissection); Single Interspace Cervical | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 28 Original policy |
| 22857 | Total Disc Arthroplasty (Artificial Disc) Anterior Approach Including Discectomy To Prepare Interspace (Other Than For Decompression); Single Interspace Lumbar | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 29 Original policy |
| 22858 | Total Disc Arthroplasty (Artificial Disc) Anterior Approach Including Discectomy With End Plate Preparation (Includes Osteophytectomy For Nerve Root Or Spinal Cord Decompression And Microdissection); Second Level Cervical (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 29 Original policy |
| 22859 | Insertion Of Intervertebral Biomechanical Device(S) (Eg Synthetic Cage Mesh Methylmethacrylate) To Intervertebral Disc Space Or Vertebral Body Defect Without Interbody Arthrodesis Each Contiguous Defect (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 30 Original policy |
| 22860 | Total Disc Arthroplasty (Artificial Disc) Anterior Approach Including Discectomy To Prepare Interspace (Other Than For Decompression); Second Interspace Lumbar (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 30 Original policy |