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Blue Cross Blue Shield Oklahoma prior authorization, page 27

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
77412Radiation Treatment Delivery >=1 Mev; Complex2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 213 Original policy
77424Intraoperative Radiation Treatment Delivery X-Ray Single Treatment Session2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 213 Original policy
77425Intraoperative Radiation Treatment Delivery Electrons Single Treatment Session2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 213 Original policy
77432Stereotactic Radiation Treatment Management Of Cranial Lesion(S) (Complete Course Of Treatment Consisting Of 1 Session)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 213 Original policy
77435Stereotactic Body Radiation Therapy Treatment Management Per Treatment Course 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 213 Original policy
77469Intraoperative Radiation Treatment Management2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 213 Original policy
77470Special Treatment Procedure (Eg Total Body Irradiation Hemibody Radiation Per Oral Or Endocavitary Irradiation)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 213 Original policy
77520Proton Treatment Delivery; Simple Without Compensation2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 214 Original policy
77522Proton Treatment Delivery; Simple With Compensation2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 214 Original policy
77523Proton Treatment Delivery; Intermediate2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 214 Original policy
77525Proton Treatment Delivery; Complex2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 214 Original policy
77750Infusion Or Instillation Of Radioelement Solution (Includes 3- Month Follow-Up Care)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 214 Original policy
77761Intracavitary Radiation Source Application; Simple2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 214 Original policy
77762Intracavitary Radiation Source Application; Intermediate2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 214 Original policy
77763Intracavitary Radiation Source Application; Complex2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 214 Original policy
77767Remote Afterloading High Dose Rate Radionuclide Skin Surface Brachytherapy Includes Basic Dosimetry When Performed; Lesion Diameter Up To 2.0 Cm Or 1 Channel2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 214 Original policy
77768Remote Afterloading High Dose Rate Radionuclide Skin Surface Brachytherapy Includes Basic Dosimetry When Performed; Lesion Diameter Over 2.0 Cm And 2 Or More Channels Or Multiple Lesions2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 214 Original policy
77770Remote Afterloading High Dose Rate Radionuclide Interstitial Or Intracavitary Brachytherapy Includes Basic Dosimetry When Performed; 1 Channel2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 214 Original policy
77771Remote Afterloading High Dose Rate Radionuclide Interstitial Or Intracavitary Brachytherapy Includes Basic Dosimetry When Performed; 2-12 Channels2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 214 Original policy
77772Remote Afterloading High Dose Rate Radionuclide Interstitial Or Intracavitary Brachytherapy Includes Basic Dosimetry When Performed; Over 12 Channels2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 215 Original policy
77778Interstitial Radiation Source Application Complex Includes Supervision Handling Loading Of Radiation Source When Performed2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 215 Original policy
77790Supervision Handling Loading Of Radiation Source2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 215 Original policy
79101Radiopharmaceutical Therapy By Intravenous Administration2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 215 Original policy
79403Radiopharmaceutical Therapy Radiolabeled Monoclonal Antibody By Intravenous Infusion2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 215 Original policy
0394THigh Dose Rate Electronic Brachytherapy Skin Surface Application Per Fraction Includes Basic Dosimetry When Performed2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 215 Original policy
0395THigh Dose Rate Electronic Brachytherapy Interstitial Or Intracavitary Treatment Per Fraction Includes Basic Dosimetry When Performed2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 215 Original policy
A9508Iodine I-131 Iobenguane Sulfate Diagnostic Per 0.5 Millicurie2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 215 Original policy
A9513Lutetium Lu 177 Dotatate Therapeutic 1 Millicurie2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 215 Original policy
A9528Iodine I-131 Sodium Iodide Capsule(S) Diagnostic Per Millicurie2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 215 Original policy
A9531Iodine I-131 Sodium Iodide Diagnostic Per Microcurie (Up To 100 Microcuries)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 215 Original policy
A9543Yttrium Y-90 Ibritumomab Tiuxetan Therapeutic Per Treatment Dose Up To 40 Millicuries2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 215 Original policy
A9590Iodine I-131 Iobenguane 1 Millicurie2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 216 Original policy
A9600Strontium Sr-89 Chloride Therapeutic Per Millicurie2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 216 Original policy
A9604Samarium Sm-153 Lexidronam Therapeutic Per Treatment Dose Up To 150 Millicuries2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 216 Original policy
A9606Radium Ra-223 Dichloride Therapeutic Per Microcurie2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 216 Original policy
A9607Lutetium Lu 177 Vipivotide Tetraxetan Therapeutic 1 Millicurie2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 216 Original policy
G0339Image-Guided Robotic Linear Accelerator-Based Stereotactic Radiosurgery Complete Course Of Therapy In One Session Or First Session Of Fractionated Treatment2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 216 Original policy
G0340Image-Guided Robotic Linear Accelerator-Based Stereotactic Radiosurgery Delivery Including Collimator Changes And Custom Plugging Fractionated Treatment All Lesions Per Session Second Through Fifth Sessions Maximum Five Sessions Per Course Of Treatment2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 216 Original policy
G0458Low Dose Rate (Ldr) Prostate Brachytherapy Services Composite Rate2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 216 Original policy
G6001Ultrasonic Guidance For Placement Of Radiation Therapy Fields2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 216 Original policy
G6002Stereoscopic X-Ray Guidance For Localization Of Target Volume For The Delivery Of Radiation Therapy2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 216 Original policy
G6003Radiation Treatment Delivery Single Treatment Area Single Port Or Parallel Opposed Ports Simple Blocks Or No Blocks: Up To 5Mev2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 216 Original policy
G6004Radiation Treatment Delivery Single Treatment Area Single Port Or Parallel Opposed Ports Simple Blocks Or No Blocks: 6-10Mev2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 217 Original policy
G6005Radiation Treatment Delivery Single Treatment Area Single Port Or Parallel Opposed Ports Simple Blocks Or No Blocks: 11-19Mev2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 217 Original policy
G6006Radiation Treatment Delivery Single Treatment Area Single Port Or Parallel Opposed Ports Simple Blocks Or No Blocks: 20Mev Or Greater2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 217 Original policy
G6007Radiation Treatment Delivery 2 Separate Treatment Areas 3 Or More Ports On A Single Treatment Area Use Of Multiple Blocks: Up To 5Mev2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 217 Original policy
G6008Radiation Treatment Delivery 2 Separate Treatment Areas 3 Or More Ports On A Single Treatment Area Use Of Multiple Blocks: 6- 10Mev2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 217 Original policy
G6009Radiation Treatment Delivery 2 Separate Treatment Areas 3 Or More Ports On A Single Treatment Area Use Of Multiple Blocks: 11- 19Mev2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 217 Original policy
G6010Radiation Treatment Delivery 2 Separate Treatment Areas 3 Or More Ports On A Single Treatment Area Use Of Multiple Blocks: 20 Mev Or Greater2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 217 Original policy
G6011Radiation Treatment Delivery 3 Or More Separate Treatment Areas Custom Blocking Tangential Ports Wedges Rotational Beam Compensators Electron Beam; Up To 5Mev2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 217 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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