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Blue Cross and Blue Shield of Montana prior authorization, page 6

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
47135Liver Allotransplantation Orthotopic Partial Or Whole From Cadaver Or Living Donor Any Age2026 Commercial Medical Surgical Prior Authorization Code List, Pg 45 Original policy
47382Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency2026 Commercial Medical Surgical Prior Authorization Code List, Pg 45 Original policy
47384Ablation, irreversible electroporation, liver, 1 or more tumors, including imaging guidance, percutaneous2026 Commercial Medical Surgical Prior Authorization Code List, Pg 45 Original policy
48160Pancreatectomy Total Or Subtotal With Autologous Transplantation Of Pancreas Or Pancreatic Islet Cells2026 Commercial Medical Surgical Prior Authorization Code List, Pg 45 Original policy
48554Transplantation Of Pancreatic Allograft2026 Commercial Medical Surgical Prior Authorization Code List, Pg 45 Original policy
50360Renal Allotransplantation Implantation Of Graft; Without Recipient Nephrectomy2026 Commercial Medical Surgical Prior Authorization Code List, Pg 45 Original policy
50365Renal Allotransplantation Implantation Of Graft; With Recipient Nephrectomy2026 Commercial Medical Surgical Prior Authorization Code List, Pg 45 Original policy
50380Reimplantation Of Kidney2026 Commercial Medical Surgical Prior Authorization Code List, Pg 45 Original policy
50592Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency2026 Commercial Medical Surgical Prior Authorization Code List, Pg 45 Original policy
52442Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 46 Original policy
54125Amputation of penis; complete2026 Commercial Medical Surgical Prior Authorization Code List, Pg 46 Original policy
54400Insertion of penile prosthesis; non- inflatable (semi-rigid)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 46 Original policy
54401Insertion of penile prosthesis; inflatable (self-contained)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 46 Original policy
54405Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir2026 Commercial Medical Surgical Prior Authorization Code List, Pg 46 Original policy
54410Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session2026 Commercial Medical Surgical Prior Authorization Code List, Pg 46 Original policy
54411Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue2026 Commercial Medical Surgical Prior Authorization Code List, Pg 46 Original policy
54416Removal and replacement of non- inflatable (semi-rigid) or inflatable (self- contained) penile prosthesis at the same operative session2026 Commercial Medical Surgical Prior Authorization Code List, Pg 46 Original policy
54417Removal and replacement of non- inflatable (semi-rigid) or inflatable (self- contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue2026 Commercial Medical Surgical Prior Authorization Code List, Pg 47 Original policy
54660Insertion of testicular prosthesis (separate procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 47 Original policy
55860Exposure Of Prostate Any Approach For Insertion Of Radioactive Substance2026 Commercial Medical Surgical Prior Authorization Code List, Pg 47 Original policy
55862Exposure Of Prostate Any Approach For Insertion Of Radioactive Substance; With Lymph Node Biopsy(S) (Limited Pelvic Lymphadenectomy)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 47 Original policy
55865Exposure Of Prostate Any Approach For Insertion Of Radioactive Substance; With Bilateral Pelvic Lymphadenectomy Including External Iliac Hypogastric And Obturator Nodes2026 Commercial Medical Surgical Prior Authorization Code List, Pg 47 Original policy
55874Transperineal Placement Of Biodegradable Material Peri-Prostatic Single Or Multiple Injection(S) Including Image Guidance When Performed2026 Commercial Medical Surgical Prior Authorization Code List, Pg 47 Original policy
55875Transperineal Placement Of Needles Or Catheters Into Prostate For Interstitial Radioelement Application With Or Without Cystoscopy2026 Commercial Medical Surgical Prior Authorization Code List, Pg 47 Original policy
55920Placement Of Needles Or Catheters Into Pelvic Organs And/Or Genitalia (Except Prostate) For Subsequent Interstitial Radioelement Application2026 Commercial Medical Surgical Prior Authorization Code List, Pg 48 Original policy
55970Intersex surgery; male to female2026 Commercial Medical Surgical Prior Authorization Code List, Pg 48 Original policy
55980Intersex surgery; female to male2026 Commercial Medical Surgical Prior Authorization Code List, Pg 48 Original policy
56805Clitoroplasty for intersex state2026 Commercial Medical Surgical Prior Authorization Code List, Pg 48 Original policy
56810Perineoplasty, repair of perineum, nonobstetrical (separate procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 48 Original policy
57155Insertion Of Uterine Tandem And/Or Vaginal Ovoids For Clinical Brachytherapy2026 Commercial Medical Surgical Prior Authorization Code List, Pg 48 Original policy
57156Insertion Of A Vaginal Radiation Afterloading Apparatus For Clinical Brachytherapy2026 Commercial Medical Surgical Prior Authorization Code List, Pg 48 Original policy
57291Construction of artificial vagina; without graft2026 Commercial Medical Surgical Prior Authorization Code List, Pg 48 Original policy
57292Construction of artificial vagina; with graft2026 Commercial Medical Surgical Prior Authorization Code List, Pg 48 Original policy
57295Revision (including removal) of prosthetic vaginal graft, vaginal approach2026 Commercial Medical Surgical Prior Authorization Code List, Pg 48 Original policy
57296Revision (including removal) of prosthetic vaginal graft; open abdominal approach2026 Commercial Medical Surgical Prior Authorization Code List, Pg 48 Original policy
57335Vaginoplasty for intersex state2026 Commercial Medical Surgical Prior Authorization Code List, Pg 48 Original policy
57426Revision (including removal) of prosthetic vaginal graft, laparoscopic approach2026 Commercial Medical Surgical Prior Authorization Code List, Pg 48 Original policy
58346Insertion Of Heyman Capsules For Clinical Brachytherapy2026 Commercial Medical Surgical Prior Authorization Code List, Pg 49 Original policy
61796Stereotactic Radiosurgery (Particle Beam Gamma Ray Or Linear Accelerator); 1 Simple Cranial Lesion2026 Commercial Medical Surgical Prior Authorization Code List, Pg 49 Original policy
61797Stereotactic Radiosurgery (Particle Beam Gamma Ray Or Linear Accelerator); Each Additional Cranial Lesion Simple (List Separately In Addition To Code For Primary Procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 49 Original policy
61798Stereotactic Radiosurgery (Particle Beam Gamma Ray Or Linear Accelerator); 1 Complex Cranial Lesion2026 Commercial Medical Surgical Prior Authorization Code List, Pg 49 Original policy
61799Stereotactic Radiosurgery (Particle Beam Gamma Ray Or Linear Accelerator); Each Additional Cranial Lesion Complex (List Separately In Addition To Code For Primary Procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 49 Original policy
61800Application Of Stereotactic Headframe For Stereotactic Radiosurgery (List Separately In Addition To Code For Primary Procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 49 Original policy
61863Twist Drill Burr Hole Craniotomy Or Craniectomy With Stereotactic Implantation Of Neurostimulator Electrode Array In Subcortical Site (Eg Thalamus Globus Pallidus Subthalamic Nucleus Periventricular Periaqueductal Gray) Without Use Of Intraoperative Microelectrode Recording; First Array2026 Commercial Medical Surgical Prior Authorization Code List, Pg 50 Original policy
61864Twist Drill Burr Hole Craniotomy Or Craniectomy With Stereotactic Implantation Of Neurostimulator Electrode Array In Subcortical Site (Eg Thalamus Globus Pallidus Subthalamic Nucleus Periventricular Periaqueductal Gray) Without Use Of Intraoperative Microelectrode Recording; Each Additional Array (List Separately In Addition To Primary Procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 50 Original policy
61867Twist Drill Burr Hole Craniotomy Or Craniectomy With Stereotactic Implantation Of Neurostimulator Electrode Array In Subcortical Site (Eg Thalamus Globus Pallidus Subthalamic Nucleus Periventricular Periaqueductal Gray) With Use Of Intraoperative Microelectrode Recording; First Array2026 Commercial Medical Surgical Prior Authorization Code List, Pg 50 Original policy
61868Twist Drill Burr Hole Craniotomy Or Craniectomy With Stereotactic Implantation Of Neurostimulator Electrode Array In Subcortical Site (Eg Thalamus Globus Pallidus Subthalamic Nucleus Periventricular Periaqueductal Gray) With Use Of Intraoperative Microelectrode Recording; Each Additional Array (List Separately In Addition To Primary Procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 51 Original policy
62380Endoscopic Decompression Of Spinal Cord Nerve Root(S) Including Laminotomy Partial Facetectomy Foraminotomy Discectomy And/Or Excision Of Herniated Intervertebral Disc 1 Interspace Lumbar2026 Commercial Medical Surgical Prior Authorization Code List, Pg 51 Original policy
63001Laminectomy With Exploration And/Or Decompression Of Spinal Cord And/Or Cauda Equina Without Facetectomy Foraminotomy Or Discectomy (Eg Spinal Stenosis) 1 Or 2 Vertebral Segments; Cervical2026 Commercial Medical Surgical Prior Authorization Code List, Pg 51 Original policy
63003Laminectomy With Exploration And/Or Decompression Of Spinal Cord And/Or Cauda Equina Without Facetectomy Foraminotomy Or Discectomy (Eg Spinal Stenosis) 1 Or 2 Vertebral Segments; Thoracic2026 Commercial Medical Surgical Prior Authorization Code List, Pg 51 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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