Blue Cross and Blue Shield of Montana prior authorization, page 32

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
Code	Description	Source
S9347	Home infusion therapy, uninterrupted, long-BCBSMT term, controlled rate intravenous or subcutaneous infusion therapy (e. G. Epoprostenol); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 292 Original policy
S9348	Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e. G. , dobutamine); administrative services, professional pharmacy services, care coordination, all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 292 Original policy
S9349	Hit Tocolysis Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 292 Original policy
S9351	Hit Cont Antiemetic Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 292 Original policy
S9353	Hit Cont Insulin Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 292 Original policy
S9355	Home Infusion Therapy Chelation Therapy; Administrative Services Professional Pharmacy Services Care Coordination And All Necessary Supplies And Equipment (Drugs And Nursing Visits Coded Separately) Per Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 292 Original policy
S9357	Home infusion therapy, enzyme replacement intravenous therapy; (e. G. Imiglucerase); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 293 Original policy
S9359	Home infusion therapy, anti-tumor necrosis factor intravenous therapy; (e. G. Infliximab); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 293 Original policy
S9361	Hit Diuretic Infus Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 293 Original policy
S9363	Hit Anti-Spasmotic Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 293 Original policy
S9364	Home Infusion Therapy Total Parenteral Nutrition (Tpn); Administrative Services Professional Pharmacy Services Care Coordination And All Necessary Supplies And Equipment Including Standard Tpn Formula (Lipids Specialty Amino Acid Formulas Drugs Other Than In Standard Formula And Nursing Visits Coded Separately) Per Diem (Do Not Use With Home Infusion Codes S9365-S9368 Using Daily Volume Scales)	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 293 Original policy
S9365	Home Infusion Therapy Total Parenteral Nutrition (Tpn); One Liter Per Day Administrative Services Professional Pharmacy Services Care Coordination And All Necessary Supplies And Equipment Including Standard Tpn Formula (Lipids Specialty Amino Acid Formulas Drugs Other Than In Standard Formula And Nursing Visits Coded Separately) Per Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 294 Original policy
S9366	Home Infusion Therapy Total Parenteral Nutrition (Tpn); More Than One Liter But No More Than Two Liters Per Day Administrative Services Professional Pharmacy Services Care Coordination And All Necessary Supplies And Equipment Including Standard Tpn Formula (Lipids Specialty Amino Acid Formulas Drugs Other Than In Standard Formula And Nursing Visits Coded Separately) Per Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 294 Original policy
S9367	Home Infusion Therapy Total Parenteral Nutrition (Tpn); More Than Two Liters But No More Than Three Liters Per Day Administrative Services Professional Pharmacy Services Care Coordination And All Necessary Supplies And Equipment Including Standard Tpn Formula (Lipids Specialty Amino Acid Formulas Drugs Other Than In Standard Formula And Nursing Visits Coded Separately) Per Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 295 Original policy
S9368	Home Infusion Therapy Total Parenteral Nutrition (Tpn); More Than Three Liters Per Day Administrative Services Professional Pharmacy Services Care Coordination And All Necessary Supplies And Equipment Including Standard Tpn Formula (Lipids Specialty Amino Acid Formulas Drugs Other Than In Standard Formula And Nursing Visits Coded Separately) Per Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 295 Original policy
S9370	Ht Inj Antiemetic Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 295 Original policy
S9372	Home therapy; intermittent anticoagulant injection therapy (e. G. Heparin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code for flushing of infusion devices with heparin to maintain patency)	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 296 Original policy
S9373	Home infusion therapy, hydration therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use with hydration therapy codes s9374-s9377 using daily volume scales)	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 296 Original policy
S9374	Hit Hydra 1 Liter Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 296 Original policy
S9375	Home infusion therapy, hydration therapy; more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 296 Original policy
S9376	Home infusion therapy, hydration therapy; more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 297 Original policy
S9377	Hit Hydra Over 3L Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 297 Original policy
S9379	Home Infusion Therapy Infusion Therapy Not Otherwise Classified; Administrative Services Professional Pharmacy Services Care Coordination And All Necessary Supplies And Equipment (Drugs And Nursing Visits Coded Separately) Per Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 297 Original policy
S9490	Hit Corticosteroid/Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 297 Original policy
S9494	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code with home infusion codes for hourly dosing schedules s9497-s9504)	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 297 Original policy
S9497	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 3 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 298 Original policy
S9500	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 298 Original policy
S9501	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 298 Original policy
S9502	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 298 Original policy
S9503	Hit Antibiotic Q6H Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 298 Original policy
S9504	Hit Antibiotic Q4H Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 299 Original policy
S9529	Venipuncture Home/Snf	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 299 Original policy
S9537	Home Therapy; Hematopoietic Hormone Injection Therapy (E. G. Erythropoietin G- Csf Gm-Csf); Administrative Services Professional Pharmacy Services Care Coordination And All Necessary Supplies And Equipment (Drugs And Nursing Visits Coded Separately) Per Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 299 Original policy
S9538	Hit Blood Products Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 299 Original policy
S9542	Home Injectable Therapy Not Otherwise Classified Including Administrative Services Professional Pharmacy Services Care Coordination And All Necessary Supplies And Equipment (Drugs And Nursing Visits Coded Separately) Per Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 299 Original policy
S9558	Home Injectable Therapy; Growth Hormone Including Administrative Services Professional Pharmacy Services Care Coordination And All Necessary Supplies And Equipment (Drugs And Nursing Visits Coded Separately) Per Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 299 Original policy
S9559	Hit Inj Interferon Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 299 Original policy
S9560	Home Injectable Therapy; Hormonal Therapy (E. G. ; Leuprolide Goserelin) Including Administrative Services Professional Pharmacy Services Care Coordination And All Necessary Supplies And Equipment (Drugs And Nursing Visits Coded Separately) Per Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 300 Original policy
S9562	Home Injectable Therapy Palivizumab Or Other Monoclonal Antibody For Rsv Including Administrative Services Professional Pharmacy Services Care Coordination And All Necessary Supplies And Equipment (Drugs And Nursing Visits Coded Separately) Per Diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 300 Original policy
S9590	Home therapy, irrigation therapy (e. G. Sterile irrigation of an organ or anatomical cavity); including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 300 Original policy
S9810	Home therapy; professional pharmacy services for provision of infusion, specialty drug administration, and/or disease state management, not otherwise classified, per hour (do not use this code with any per diem code)	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 300 Original policy
S9960	Ambulance service, conventional air service, nonemergency transport, one way (fixed wing)	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 301 Original policy
S9961	Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 301 Original policy
S9988	Services provided as part of a phase i clinical trial	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 301 Original policy
S9990	Services provided as part of a phase ii clinical trial	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 301 Original policy
S9991	Services provided as part of a phase iii clinical trial	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 301 Original policy
T1000	Private duty/independent nsg	2026 Commercial Medical Surgical Prior Authorization Code List, Pg 301 Original policy
90283	Immune Globulin (Igiv) BCBSMT Human For Intravenous Use	2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 1 Original policy
90284	Immune Globulin (Scig) BCBSMT Human For Use In Subcutaneous Infusions 100 Mg Each	2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 2 Original policy
C9399	Unclassified Drugs Or Carelon Biologicals	2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 2 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.

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