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Blue Cross and Blue Shield of Montana prior authorization, page 5

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
37243Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction2026 Commercial Medical Surgical Prior Authorization Code List, Pg 39 Original policy
37500Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 39 Original policy
37700Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions2026 Commercial Medical Surgical Prior Authorization Code List, Pg 39 Original policy
37718Ligation, division, and stripping, short saphenous vein2026 Commercial Medical Surgical Prior Authorization Code List, Pg 39 Original policy
37722Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below2026 Commercial Medical Surgical Prior Authorization Code List, Pg 39 Original policy
37735Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia2026 Commercial Medical Surgical Prior Authorization Code List, Pg 40 Original policy
37760Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when performed, open,1 leg2026 Commercial Medical Surgical Prior Authorization Code List, Pg 40 Original policy
37761Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg2026 Commercial Medical Surgical Prior Authorization Code List, Pg 40 Original policy
37765Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions2026 Commercial Medical Surgical Prior Authorization Code List, Pg 40 Original policy
37766Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions2026 Commercial Medical Surgical Prior Authorization Code List, Pg 40 Original policy
37780Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 40 Original policy
37785Ligation, division, and/or excision of varicose vein cluster(s), 1 leg2026 Commercial Medical Surgical Prior Authorization Code List, Pg 40 Original policy
38204Management Of Recipient Hematopoietic Progenitor Cell Donor Search And Cell Acquisition2026 Commercial Medical Surgical Prior Authorization Code List, Pg 40 Original policy
38205Blood-Derived Hematopoietic Progenitor Cell Harvesting For Transplantation Per Collection; Allogeneic2026 Commercial Medical Surgical Prior Authorization Code List, Pg 40 Original policy
38206Blood-Derived Hematopoietic Progenitor Cell Harvesting For Transplantation Per Collection; Autologous2026 Commercial Medical Surgical Prior Authorization Code List, Pg 41 Original policy
38207Transplant Preparation Of Hematopoietic Progenitor Cells; Cryopreservation And Storage2026 Commercial Medical Surgical Prior Authorization Code List, Pg 41 Original policy
38230Bone Marrow Harvesting For Transplantation; Allogeneic2026 Commercial Medical Surgical Prior Authorization Code List, Pg 41 Original policy
38232Bone Marrow Harvesting For Transplantation; Autologous2026 Commercial Medical Surgical Prior Authorization Code List, Pg 41 Original policy
38240Hematopoietic Progenitor Cell (Hpc); Allogeneic Transplantation Per Donor2026 Commercial Medical Surgical Prior Authorization Code List, Pg 41 Original policy
38241Hematopoietic Progenitor Cell (Hpc); Autologous Transplantation2026 Commercial Medical Surgical Prior Authorization Code List, Pg 41 Original policy
38242Allogeneic Lymphocyte Infusions2026 Commercial Medical Surgical Prior Authorization Code List, Pg 41 Original policy
38243Hematopoietic Progenitor Cell (Hpc); Hpc Boost2026 Commercial Medical Surgical Prior Authorization Code List, Pg 41 Original policy
41019Placement Of Needles Catheters Or Other Device(S) Into The Head And/Or Neck Region (Percutaneous Transoral Or Transnasal) For Subsequent Interstitial Radioelement Application2026 Commercial Medical Surgical Prior Authorization Code List, Pg 41 Original policy
43281Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of me2026 Commercial Medical Surgical Prior Authorization Code List, Pg 41 Original policy
43284Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed2026 Commercial Medical Surgical Prior Authorization Code List, Pg 42 Original policy
43632Gastrectomy, partial, distal; with gastrojejunostomy2026 Commercial Medical Surgical Prior Authorization Code List, Pg 42 Original policy
43633Gastrectomy, partial, distal; with Roux-en-Y reconstruction2026 Commercial Medical Surgical Prior Authorization Code List, Pg 42 Original policy
43634Gastrectomy, partial, distal; with formation of intestinal pouch2026 Commercial Medical Surgical Prior Authorization Code List, Pg 42 Original policy
43644Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux- en-Y gastroenterostomy (roux limb 150 cm or less)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 42 Original policy
43645Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption2026 Commercial Medical Surgical Prior Authorization Code List, Pg 42 Original policy
43647Laparoscopy Surgical; Implantation Or Replacement Of Gastric Neurostimulator Electrodes Antrum2026 Commercial Medical Surgical Prior Authorization Code List, Pg 42 Original policy
43648Laparoscopy Surgical; Revision Or Removal Of Gastric Neurostimulator Electrodes Antrum2026 Commercial Medical Surgical Prior Authorization Code List, Pg 42 Original policy
43770Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 43 Original policy
43771Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only2026 Commercial Medical Surgical Prior Authorization Code List, Pg 43 Original policy
43772Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only2026 Commercial Medical Surgical Prior Authorization Code List, Pg 43 Original policy
43773Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only2026 Commercial Medical Surgical Prior Authorization Code List, Pg 43 Original policy
43774Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components2026 Commercial Medical Surgical Prior Authorization Code List, Pg 43 Original policy
43775Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 43 Original policy
43842Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical- banded gastroplasty2026 Commercial Medical Surgical Prior Authorization Code List, Pg 43 Original policy
43843Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty2026 Commercial Medical Surgical Prior Authorization Code List, Pg 43 Original policy
43845Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 44 Original policy
43846Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy2026 Commercial Medical Surgical Prior Authorization Code List, Pg 44 Original policy
43847Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption2026 Commercial Medical Surgical Prior Authorization Code List, Pg 44 Original policy
43848Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 44 Original policy
43860Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy2026 Commercial Medical Surgical Prior Authorization Code List, Pg 44 Original policy
43865Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy2026 Commercial Medical Surgical Prior Authorization Code List, Pg 44 Original policy
43881Implantation Or Replacement Of Gastric Neurostimulator Electrodes Antrum Open2026 Commercial Medical Surgical Prior Authorization Code List, Pg 44 Original policy
43889Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG), including argon plasma coagulation, when performed2026 Commercial Medical Surgical Prior Authorization Code List, Pg 45 Original policy
44135Intestinal Allotransplantation; From Cadaver Donor2026 Commercial Medical Surgical Prior Authorization Code List, Pg 45 Original policy
44136Intestinal Allotransplantation; From Living Donor2026 Commercial Medical Surgical Prior Authorization Code List, Pg 45 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.

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