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Blue Cross and Blue Shield of Montana prior authorization, page 30

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
L6945Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device2026 Commercial Medical Surgical Prior Authorization Code List, Pg 275 Original policy
L6960Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device2026 Commercial Medical Surgical Prior Authorization Code List, Pg 275 Original policy
L6970Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device2026 Commercial Medical Surgical Prior Authorization Code List, Pg 275 Original policy
L6975Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device2026 Commercial Medical Surgical Prior Authorization Code List, Pg 275 Original policy
L7040Prehensile actuator, switch controlled2026 Commercial Medical Surgical Prior Authorization Code List, Pg 275 Original policy
L7045Electric hook, switch or myoelectric controlled, pediatric2026 Commercial Medical Surgical Prior Authorization Code List, Pg 276 Original policy
L7170Electronic elbow, hosmer or equal, switch controlled2026 Commercial Medical Surgical Prior Authorization Code List, Pg 276 Original policy
L7185Electronic elbow, adolescent, variety village or equal, switch controlled2026 Commercial Medical Surgical Prior Authorization Code List, Pg 276 Original policy
L7186Electronic elbow, child, variety village or equal, switch controlled2026 Commercial Medical Surgical Prior Authorization Code List, Pg 276 Original policy
L7190Electronic elbow, adolescent, variety village or equal, myoelectronically controlled2026 Commercial Medical Surgical Prior Authorization Code List, Pg 276 Original policy
L7191Electronic elbow, child, variety village or equal, myoelectronically controlled2026 Commercial Medical Surgical Prior Authorization Code List, Pg 276 Original policy
L7360Six volt battery, each2026 Commercial Medical Surgical Prior Authorization Code List, Pg 276 Original policy
L8600Implantable breast prosthesis, silicone or equal2026 Commercial Medical Surgical Prior Authorization Code List, Pg 276 Original policy
L8614Cochlear device, includes all internal and external components2026 Commercial Medical Surgical Prior Authorization Code List, Pg 276 Original policy
L8628Cochlear implant, external controller component, replacement2026 Commercial Medical Surgical Prior Authorization Code List, Pg 276 Original policy
L8679Implantable Neurostimulator Pulse Generator Any Type2026 Commercial Medical Surgical Prior Authorization Code List, Pg 276 Original policy
L8680Implantable Neurostimulator Electrode Each2026 Commercial Medical Surgical Prior Authorization Code List, Pg 276 Original policy
L8685Implantable Neurostimulator Pulse Generator Single Array Rechargeable Includes Extension2026 Commercial Medical Surgical Prior Authorization Code List, Pg 277 Original policy
L8686Implantable Neurostimulator Pulse Generator Single Array Non-Rechargeable Includes Extension2026 Commercial Medical Surgical Prior Authorization Code List, Pg 277 Original policy
L8687Implantable Neurostimulator Pulse Generator Dual Array Rechargeable Includes Extension2026 Commercial Medical Surgical Prior Authorization Code List, Pg 277 Original policy
L8688Implantable Neurostimulator Pulse Generator Dual Array Non-Rechargeable Includes Extension2026 Commercial Medical Surgical Prior Authorization Code List, Pg 277 Original policy
L8690Auditory osseointegrated device, includes all internal and external components2026 Commercial Medical Surgical Prior Authorization Code List, Pg 277 Original policy
L8691Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each2026 Commercial Medical Surgical Prior Authorization Code List, Pg 278 Original policy
L8701Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated2026 Commercial Medical Surgical Prior Authorization Code List, Pg 278 Original policy
L8702Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated2026 Commercial Medical Surgical Prior Authorization Code List, Pg 278 Original policy
Q0081Infusion Ther Other Than Che2026 Commercial Medical Surgical Prior Authorization Code List, Pg 278 Original policy
Q0083Chemo By Other Than Infusion2026 Commercial Medical Surgical Prior Authorization Code List, Pg 278 Original policy
Q0084Chemotherapy By Infusion2026 Commercial Medical Surgical Prior Authorization Code List, Pg 278 Original policy
Q0085Chemo By Both Infusion And O2026 Commercial Medical Surgical Prior Authorization Code List, Pg 278 Original policy
Q3001Radioelements For Brachytherapy Any Type Each2026 Commercial Medical Surgical Prior Authorization Code List, Pg 278 Original policy
Q4116Alloderm, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 278 Original policy
Q4122Dermacell, dermacell awm or dermacell awm porous, per square centimeter (add- on, list separately in addition to primary procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 279 Original policy
Q4128Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 279 Original policy
Q4133Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 279 Original policy
Q4158Kerecis omega3, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 279 Original policy
Q4159Affinity, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 279 Original policy
Q4186Epifix, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 279 Original policy
Q4226Myown skin, includes harvesting and preparation procedures, per square centimeter2026 Commercial Medical Surgical Prior Authorization Code List, Pg 279 Original policy
Q4392Grafix duo, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 279 Original policy
S0215Non-emergency transportation; mileage, per mile2026 Commercial Medical Surgical Prior Authorization Code List, Pg 280 Original policy
S2053Transplantation Of Small Intestine And Liver Allografts2026 Commercial Medical Surgical Prior Authorization Code List, Pg 280 Original policy
S2054Transplantation Of Multivisceral Organs2026 Commercial Medical Surgical Prior Authorization Code List, Pg 280 Original policy
S2060Lobar Lung Transplantation2026 Commercial Medical Surgical Prior Authorization Code List, Pg 280 Original policy
S2065Simultaneous Pancreas Kidney Transplantation2026 Commercial Medical Surgical Prior Authorization Code List, Pg 280 Original policy
S2102Islet Cell Tissue Transplant From Pancreas; Allogeneic2026 Commercial Medical Surgical Prior Authorization Code List, Pg 280 Original policy
S2112Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 280 Original policy
S2140Cord Blood Harvesting For Transplantation Allogeneic2026 Commercial Medical Surgical Prior Authorization Code List, Pg 280 Original policy
S2142Cord Blood-Derived Stem-Cell Transplantation Allogeneic2026 Commercial Medical Surgical Prior Authorization Code List, Pg 280 Original policy
S2150Bone Marrow Or Blood-Derived Stem Cells (Peripheral Or Umbilical) Allogeneic Or Autologous Harvesting Transplantation And Related Complications; Including: Pheresis And Cell Preparation/Storage; Marrow Ablative Therapy; Drugs Supplies Hospitalization With Outpatient Follow-Up; Medical/Surgical Diagnostic Emergency And Rehabilitative Services; And The Number Of Days Of Pre-And Post- Transplant Care In The Global Definition2026 Commercial Medical Surgical Prior Authorization Code List, Pg 281 Original policy
S3800Genetic Testing For Amyotrophic Lateral Sclerosis (Als)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 281 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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