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Blue Cross Blue Shield Oklahoma prior authorization, page 25

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
0218TInjection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Ultrasound Guidance Lumbar Or Sacral; Third And Any Additional Level(S) (List Separately In Addition To Code For Primary Procedure)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 201 Original policy
0627TPercutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 201 Original policy
0628TPercutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; each additional level (List separately in addition to code for primary procedure)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 202 Original policy
0629TPercutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 202 Original policy
0630TPercutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; each additional level (List separately in addition to code for primary procedure)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 202 Original policy
61850Twist Drill Or Burr Hole(S) For Implantation Of Neurostimulator Electrodes Cortical2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 202 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 202 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 203 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 203 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 203 Original policy
64561Percutaneous Implantation Of Neurostimulator Electrode Array; Sacral Nerve (Transforaminal Placement) Including Image Guidance If Performed2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 203 Original policy
64581Open Implantation Of Neurostimulator Electrode Array; Sacral Nerve (Transforaminal Placement)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
A4290Sacral Nerve Stimulation Test Lead Each2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
E0745Neuromuscular Stimulator Electronic Shock Unit2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
19316Mastopexy2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
19318Breast Reduction2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
L8600Implantable Breast Prosthesis Silicone Or Equal2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
15824Rhytidectomy; Forehead2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
15826Rhytidectomy; Glabellar Frown Lines2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
30130Excision Inferior Turbinate Partial Or Complete Any Method2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
30140Submucous Resection Inferior Turbinate Partial Or Complete Any Method2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
30520Septoplasty Or Submucous Resection With Or Without Cartilage Scoring Contouring Or Replacement With Graft2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
64716Neuroplasty And/Or Transposition; Cranial Nerve (Specify)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
64732Transection Or Avulsion Of; Supraorbital Nerve2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
64734Transection Or Avulsion Of; Infraorbital Nerve2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
64771Transection Or Avulsion Of Other Cranial Nerve Extradural2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
67900Repair Of Brow Ptosis (Supraciliary Mid-Forehead Or Coronal Approach)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
21085Impression And Custom Preparation; Oral Surgical Splint2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 204 Original policy
21110Application Of Interdental Fixation Device For Conditions Other Than Fracture Or Dislocation Includes Removal2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 205 Original policy
21125Augmentation Mandibular Body Or Angle; Prosthetic Material2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 205 Original policy
21127Augmentation Mandibular Body Or Angle; With Bone Graft Onlay Or Interpositional (Includes Obtaining Autograft)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 205 Original policy
21141Reconstruction Midface Lefort I; Single Piece Segment Movement In Any Direction (Eg For Long Face Syndrome) Without Bone Graft2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 205 Original policy
21142Reconstruction Midface Lefort I; 2 Pieces Segment Movement In Any Direction Without Bone Graft2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 205 Original policy
21143Reconstruction Midface Lefort I; 3 Or More Pieces Segment Movement In Any Direction Without Bone Graft2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 205 Original policy
21145Reconstruction Midface Lefort I; Single Piece Segment Movement In Any Direction Requiring Bone Grafts (Includes Obtaining Autografts)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 205 Original policy
21146Reconstruction Midface Lefort I; 2 Pieces Segment Movement In Any Direction Requiring Bone Grafts (Includes Obtaining Autografts) (Eg Ungrafted Unilateral Alveolar Cleft)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 205 Original policy
21147Reconstruction Midface Lefort I; 3 Or More Pieces Segment Movement In Any Direction Requiring Bone Grafts (Includes Obtaining Autografts) (Eg Ungrafted Bilateral Alveolar Cleft Or Multiple Osteotomies)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 205 Original policy
21150Reconstruction Midface Lefort Ii; Anterior Intrusion (Eg Treacher- Collins Syndrome)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 206 Original policy
21151Reconstruction Midface Lefort Ii; Any Direction Requiring Bone Grafts (Includes Obtaining Autografts)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 206 Original policy
21154Reconstruction Midface Lefort Iii (Extracranial) Any Type Requiring Bone Grafts (Includes Obtaining Autografts); Without Lefort I2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 206 Original policy
21155Reconstruction Midface Lefort Iii (Extracranial) Any Type Requiring Bone Grafts (Includes Obtaining Autografts); With Lefort I2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 206 Original policy
21159Reconstruction Midface Lefort Iii (Extra And Intracranial) With Forehead Advancement (Eg Mono Bloc) Requiring Bone Grafts (Includes Obtaining Autografts); Without Lefort I2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 206 Original policy
21160Reconstruction Midface Lefort Iii (Extra And Intracranial) With Forehead Advancement (Eg Mono Bloc) Requiring Bone Grafts (Includes Obtaining Autografts); With Lefort I2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 206 Original policy
21188Reconstruction Midface Osteotomies (Other Than Lefort Type) And Bone Grafts (Includes Obtaining Autografts)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 206 Original policy
21193Reconstruction Of Mandibular Rami Horizontal Vertical C Or L Osteotomy; Without Bone Graft2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 206 Original policy
21194Reconstruction Of Mandibular Rami Horizontal Vertical C Or L Osteotomy; With Bone Graft (Includes Obtaining Graft)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 206 Original policy
21195Reconstruction Of Mandibular Rami And/Or Body Sagittal Split; Without Internal Rigid Fixation2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 207 Original policy
21196Reconstruction Of Mandibular Rami And/Or Body Sagittal Split; With Internal Rigid Fixation2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 207 Original policy
21198Osteotomy Mandible Segmental2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 207 Original policy
21199Osteotomy Mandible Segmental; With Genioglossus Advancement2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 207 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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