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Blue Cross Blue Shield Oklahoma prior authorization, page 26

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
21206Osteotomy Maxilla Segmental (Eg Wassmund Or Schuchard)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 207 Original policy
21208Osteoplasty Facial Bones; Augmentation (Autograft Allograft Or Prosthetic Implant)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 207 Original policy
21209Osteoplasty Facial Bones; Reduction2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 207 Original policy
21210Graft Bone; Nasal Maxillary Or Malar Areas (Includes Obtaining Graft)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 207 Original policy
21215Graft Bone; Mandible (Includes Obtaining Graft)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 207 Original policy
21230Graft; Rib Cartilage Autogenous To Face Chin Nose Or Ear (Includes Obtaining Graft)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 207 Original policy
64999Unlisted Procedure Nervous System2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 207 Original policy
19294Preparation Of Tumor Cavity With Placement Of A Radiation Therapy Applicator For Intraoperative Radiation Therapy (Iort) Concurrent With Partial Mastectomy (List Separately In Addition To Code For Primary Procedure)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 207 Original policy
19296Placement Of Radiotherapy Afterloading Expandable Catheter (Single Or Multichannel) Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy Includes Imaging Guidance; On Date Separate From Partial Mastectomy2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 208 Original policy
19297Placement Of Radiotherapy Afterloading Expandable Catheter (Single Or Multichannel) Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy Includes Imaging Guidance; Concurrent With Partial Mastectomy (List Separately In Addition To Code For Primary Procedure)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 208 Original policy
19298Placement Of Radiotherapy After Loading Brachytherapy Catheters (Multiple Tube And Button Type) Into The Breast For Interstitial Radioelement Application Following (At The Time Of Or Subsequent To) Partial Mastectomy Includes Imaging Guidance2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 208 Original policy
20555Placement Of Needles Or Catheters Into Muscle And/Or Soft Tissue For Subsequent Interstitial Radioelement Application (At The Time Of Or Subsequent To The Procedure)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 208 Original policy
31643Bronchoscopy Rigid Or Flexible Including Fluoroscopic Guidance When Performed; With Placement Of Catheter(S) For Intracavitary Radioelement Application2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 208 Original policy
32701Thoracic Target(S) Delineation For Stereotactic Body Radiation Therapy (Srs/Sbrt) (Photon Or Particle Beam) Entire Course Of Treatment2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 209 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 209 Original policy
55860Exposure Of Prostate Any Approach For Insertion Of Radioactive Substance2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 209 Original policy
55862Exposure Of Prostate Any Approach For Insertion Of Radioactive Substance; With Lymph Node Biopsy(S) (Limited Pelvic Lymphadenectomy)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 209 Original policy
55865Exposure Of Prostate Any Approach For Insertion Of Radioactive Substance; With Bilateral Pelvic Lymphadenectomy Including External Iliac Hypogastric And Obturator Nodes2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 209 Original policy
55874Transperineal Placement Of Biodegradable Material Peri- Prostatic Single Or Multiple Injection(S) Including Image Guidance When Performed2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 209 Original policy
55875Transperineal Placement Of Needles Or Catheters Into Prostate For Interstitial Radioelement Application With Or Without Cystoscopy2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 209 Original policy
55920Placement Of Needles Or Catheters Into Pelvic Organs And/Or Genitalia (Except Prostate) For Subsequent Interstitial Radioelement Application2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 210 Original policy
57155Insertion Of Uterine Tandem And/Or Vaginal Ovoids For Clinical Brachytherapy2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 210 Original policy
57156Insertion Of A Vaginal Radiation Afterloading Apparatus For Clinical Brachytherapy2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 210 Original policy
58346Insertion Of Heyman Capsules For Clinical Brachytherapy2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 210 Original policy
61796Stereotactic Radiosurgery (Particle Beam Gamma Ray Or Linear Accelerator); 1 Simple Cranial Lesion2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 210 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 210 Original policy
61798Stereotactic Radiosurgery (Particle Beam Gamma Ray Or Linear Accelerator); 1 Complex Cranial Lesion2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 210 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 210 Original policy
61800Application Of Stereotactic Headframe For Stereotactic Radiosurgery (List Separately In Addition To Code For Primary Procedure)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 210 Original policy
63620Stereotactic Radiosurgery (Particle Beam Gamma Ray Or Linear Accelerator); 1 Spinal Lesion2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 211 Original policy
63621Stereotactic Radiosurgery (Particle Beam Gamma Ray Or Linear Accelerator); Each Additional Spinal Lesion (List Separately In Addition To Code For Primary Procedure)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 211 Original policy
67218Destruction Of Localized Lesion Of Retina (Eg Macular Edema Tumors) 1 Or More Sessions; Radiation By Implantation Of Source (Includes Removal Of Source)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 211 Original policy
76873Ultrasound Transrectal; Prostate Volume Study For Brachytherapy Treatment Planning (Separate Procedure)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 211 Original policy
76965Ultrasonic Guidance For Interstitial Radioelement Application2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 211 Original policy
77014Computed Tomography Guidance For Placement Of Radiation Therapy Fields2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 211 Original policy
772953-Dimensional Radiotherapy Plan Including Dose-Volume Histograms2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 211 Original policy
77301Intensity Modulated Radiotherapy Plan Including Dose-Volume Histograms For Target And Critical Structure Partial Tolerance Specifications2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 211 Original policy
77316Brachytherapy Isodose Plan; Simple (Calculation[S] Made From 1 To 4 Sources Or Remote Afterloading Brachytherapy 1 Channel) Includes Basic Dosimetry Calculation(S)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 211 Original policy
77317Brachytherapy Isodose Plan; Intermediate (Calculation[S] Made From 5 To 10 Sources Or Remote Afterloading Brachytherapy 2-12 Channels) Includes Basic Dosimetry Calculation(S)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 212 Original policy
77318Brachytherapy Isodose Plan; Complex (Calculation[S] Made From Over 10 Sources Or Remote Afterloading Brachytherapy Over 12 Channels) Includes Basic Dosimetry Calculation(S)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 212 Original policy
77338Multi-Leaf Collimator (Mlc) Device(S) For Intensity Modulated Radiation Therapy (Imrt) Design And Construction Per Imrt Plan2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 212 Original policy
77370Special Medical Radiation Physics Consultation2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 212 Original policy
77371Radiation Treatment Delivery Stereotactic Radiosurgery (Srs) Complete Course Of Treatment Of Cranial Lesion(S) Consisting Of 1 Session; Multi-Source Cobalt 60 Based2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 212 Original policy
77372Radiation Treatment Delivery Stereotactic Radiosurgery (Srs) Complete Course Of Treatment Of Cranial Lesion(S) Consisting Of 1 Session; Linear Accelerator Based2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 212 Original policy
77373Stereotactic Body Radiation Therapy Treatment Delivery Per Fraction To 1 Or More Lesions Including Image Guidance Entire Course Not To Exceed 5 Fractions2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 212 Original policy
77385Intensity Modulated Radiation Treatment Delivery (Imrt) Includes Guidance And Tracking When Performed; Simple2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 213 Original policy
77386Intensity Modulated Radiation Treatment Delivery (Imrt) Includes Guidance And Tracking When Performed; Complex2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 213 Original policy
77387Guidance For Localization Of Target Volume For Delivery Of Radiation Treatment Includes Intrafraction Tracking When Performed2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 213 Original policy
77402Radiation Treatment Delivery >=1 Mev; Simple2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 213 Original policy
77407Radiation Treatment Delivery >=1 Mev; Intermediate2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 213 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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