Blue Cross and Blue Shield of Montana prior authorization, page 8
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 |
|---|---|---|
| 63285 | Laminectomy For Biopsy/Excision Of Intraspinal Neoplasm; Intradural Intramedullary Cervical | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 62 Original policy |
| 63287 | Laminectomy For Biopsy/Excision Of Intraspinal Neoplasm; Intradural Intramedullary Thoracolumbar | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 62 Original policy |
| 63290 | Laminectomy For Biopsy/Excision Of Intraspinal Neoplasm; Combined Extradural-Intradural Lesion Any Level | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 62 Original policy |
| 63300 | Vertebral Corpectomy (Vertebral Body Resection) Partial Or Complete For Excision Of Intraspinal Lesion Single Segment; Extradural Cervical | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 63 Original policy |
| 63301 | Vertebral Corpectomy (Vertebral Body Resection) Partial Or Complete For Excision Of Intraspinal Lesion Single Segment; Extradural Thoracic By Transthoracic Approach | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 63 Original policy |
| 63302 | Vertebral Corpectomy (Vertebral Body Resection) Partial Or Complete For Excision Of Intraspinal Lesion Single Segment; Extradural Thoracic By Thoracolumbar Approach | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 63 Original policy |
| 63303 | Vertebral Corpectomy (Vertebral Body Resection) Partial Or Complete For Excision Of Intraspinal Lesion Single Segment; Extradural Lumbar Or Sacral By Transperitoneal Or Retroperitoneal Approach | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 63 Original policy |
| 63304 | Vertebral Corpectomy (Vertebral Body Resection) Partial Or Complete For Excision Of Intraspinal Lesion Single Segment; Intradural Cervical | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 63 Original policy |
| 63305 | Vertebral Corpectomy (Vertebral Body Resection) Partial Or Complete For Excision Of Intraspinal Lesion Single Segment; Intradural Thoracic By Transthoracic Approach | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 63 Original policy |
| 63306 | Vertebral Corpectomy (Vertebral Body Resection) Partial Or Complete For Excision Of Intraspinal Lesion Single Segment; Intradural Thoracic By Thoracolumbar Approach | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 64 Original policy |
| 63307 | Vertebral Corpectomy (Vertebral Body Resection) Partial Or Complete For Excision Of Intraspinal Lesion Single Segment; Intradural Lumbar Or Sacral By Transperitoneal Or Retroperitoneal Approach | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 64 Original policy |
| 63308 | Vertebral Corpectomy (Vertebral Body Resection) Partial Or Complete For Excision Of Intraspinal Lesion Single Segment; Each Additional Segment (List Separately In Addition To Codes For Single Segment) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 64 Original policy |
| 63620 | Stereotactic Radiosurgery (Particle Beam Gamma Ray Or Linear Accelerator); 1 Spinal Lesion | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 64 Original policy |
| 63621 | Stereotactic Radiosurgery (Particle Beam Gamma Ray Or Linear Accelerator); Each Additional Spinal Lesion (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 64 Original policy |
| 63650 | Percutaneous Implantation Of Neurostimulator Electrode Array Epidural | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 64 Original policy |
| 63655 | Laminectomy For Implantation Of Neurostimulator Electrodes Plate/Paddle Epidural | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 65 Original policy |
| 63663 | Revision Including Replacement When Performed Of Spinal Neurostimulator Electrode Percutaneous Array(S) Including Fluoroscopy When Performed | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 65 Original policy |
| 63664 | Revision Including Replacement When Performed Of Spinal Neurostimulator Electrode Plate/Paddle(S) Placed Via Laminotomy Or Laminectomy Including Fluoroscopy When Performed | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 65 Original policy |
| 63685 | Insertion Or Replacement Of Spinal Neurostimulator Pulse Generator Or Receiver Requiring Pocket Creation And Connection Between Electrode Array And Pulse Generator Or Receiver | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 65 Original policy |
| 63688 | Revision Or Removal Of Implanted Spinal Neurostimulator Pulse Generator Or Receiver With Detachable Connection To Electrode Array | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 65 Original policy |
| 64451 | Injection(S) Anesthetic Agent(S) And/Or Steroid; Nerves Innervating The Sacroiliac Joint With Image Guidance (Ie Fluoroscopy Or Computed Tomography) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 66 Original policy |
| 64490 | Injection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Image Guidance (Fluoroscopy Or Ct) Cervical Or Thoracic; Single Level | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 66 Original policy |
| 64491 | Injection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Image Guidance (Fluoroscopy Or Ct) Cervical Or Thoracic; Second Level (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 66 Original policy |
| 64492 | Injection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Image Guidance (Fluoroscopy Or Ct) Cervical Or Thoracic; Third And Any Additional Level(S) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 66 Original policy |
| 64493 | Injection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Image Guidance (Fluoroscopy Or Ct) Lumbar Or Sacral; Single Level | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 67 Original policy |
| 64494 | Injection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Image Guidance (Fluoroscopy Or Ct) Lumbar Or Sacral; Second Level (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 67 Original policy |
| 64495 | Injection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Image Guidance (Fluoroscopy Or Ct) Lumbar Or Sacral; Third And Any Additional Level(S) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 67 Original policy |
| 64561 | Percutaneous Implantation Of Neurostimulator Electrode Array; Sacral Nerve (Transforaminal Placement) Including Image Guidance If Performed | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 67 Original policy |
| 64568 | Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 67 Original policy |
| 64575 | Open Implantation Of Neurostimulator Electrode Array; Peripheral Nerve (Excludes Sacral Nerve) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 68 Original policy |
| 64580 | Open Implantation Of Neurostimulator Electrode Array; Neuromuscular | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 68 Original policy |
| 64581 | Open Implantation Of Neurostimulator Electrode Array; Sacral Nerve (Transforaminal Placement) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 68 Original policy |
| 64590 | Insertion Or Replacement Of Peripheral Sacral Or Gastric Neurostimulator Pulse Generator Or Receiver Requiring Pocket Creation And Connection Between Electrode Array And Pulse Generator Or Receiver | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 68 Original policy |
| 64624 | Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 68 Original policy |
| 64625 | Radiofrequency Ablation Nerves Innervating The Sacroiliac Joint With Image Guidance (Ie Fluoroscopy Or Computed Tomography) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 69 Original policy |
| 64628 | Thermal destruction of intraosseous basivertebral nerve including all imaging guidance; first 2 vertebral bodies lumbar sacral | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 69 Original policy |
| 64633 | Destruction By Neurolytic Agent Paravertebral Facet Joint Nerve(S) With Imaging Guidance (Fluoroscopy Or Ct); Cervical Or Thoracic Single Facet Joint | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 69 Original policy |
| 64634 | Destruction By Neurolytic Agent Paravertebral Facet Joint Nerve(S) With Imaging Guidance (Fluoroscopy Or Ct); Cervical Or Thoracic Each Additional Facet Joint (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 69 Original policy |
| 64635 | Destruction By Neurolytic Agent Paravertebral Facet Joint Nerve(S) With Imaging Guidance (Fluoroscopy Or Ct); Lumbar Or Sacral Single Facet Joint | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 69 Original policy |
| 64636 | Destruction By Neurolytic Agent Paravertebral Facet Joint Nerve(S) With Imaging Guidance (Fluoroscopy Or Ct); Lumbar Or Sacral Each Additional Facet Joint (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 69 Original policy |
| 64640 | Destruction by neurolytic agent; other peripheral nerve or branch | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 70 Original policy |
| 66174 | Transluminal dilation of aqueous outflow canal (eg, canaloplasty); without retention of device or stent | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 70 Original policy |
| 67218 | Destruction Of Localized Lesion Of Retina (Eg Macular Edema Tumors) 1 Or More Sessions; Radiation By Implantation Of Source (Includes Removal Of Source) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 70 Original policy |
| 67900 | Repair Of Brow Ptosis (Supraciliary Mid- Forehead Or Coronal Approach) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 70 Original policy |
| 67904 | Repair of blepharoptosis; (tarso) levator resection or advancement, external approach | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 70 Original policy |
| 69705 | Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); unilateral | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 70 Original policy |
| 69706 | Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); bilateral | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 70 Original policy |
| 69714 | Implantation Osseointegrated Implant Skull; With Percutaneous Attachment To External Speech Processor | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 70 Original policy |
| 69930 | Cochlear Device Implantation With Or Without Mastoidectomy | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 70 Original policy |
| 70336 | Magnetic Resonance (Eg Proton) Imaging Temporomandibular Joint(S) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 71 Original policy |