Talk to Us

Blue Cross Blue Shield Oklahoma prior authorization, page 29

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
70473Computed tomographic (CT) cerebral perfusion analysis with contrast material(s), including image postprocessing performed without concurrent CT or CT angiography of the same anatomy2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 53 Original policy
77436Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation- aided field setting2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 69 Original policy
77437Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation- aided field setting2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 69 Original policy
77438Surface radiation therapy; orthovoltage, delivery, >150-500 kV, per fraction2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 69 Original policy
77439Surface radiation therapy; superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for treatment of cutaneous tumors, per course of treatment (List separately in addition to code for primary procedure)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 69 Original policy
81354Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of structural and copy number variants, optical genome mapping (OGM)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 105 Original policy
81524Oncology (central nervous system tumor), DNA methylation analysis of at least 10,000 methylation sites, utilizing DNA extracted from formalin-fixed tumor tissue, algorithm(s) reported as probability of matching a reference tumor family and class, and MGMT (O-6- methylguanine-DNA methyltransferase) promoter methylation status, if performed2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 127 Original policy
99601Home Infusion/Visit 2 Hrs2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 133 Original policy
99602Home Infusion Each Addtl Hr2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 133 Original policy
0605UAllergy and immunology (hereditary alpha tryptasemia), DNA, analysis of TPSAB1 gene copy number variation using digital PCR, whole blood, results reported with genotype-specific interpretation of alpha-tryptase copy number and algorithmic classification as normal or abnormal2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 194 Original policy
0611UOncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 194 Original policy
0612UOncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 194 Original policy
0613UOncology (urothelial carcinoma), DNA methylation and mutation analysis of 6 biomarkers (TWIST1, OTX1, ONECUT2, FGFR3, HRAS, TERT promoter region), methylation- specific PCR and targeted next-generation sequencing, urine, algorithm reported as a probability index for bladder cancer and upper tract urothelial carcinoma2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 194 Original policy
0628UNephrology (kidney disease-related genetic conditions), genomic analysis, renal disease panel, saliva, DNA, next-generation sequencing of 449 genes, reported as pathogenic or likely pathogenic variants of uncertain significance or risk alleles2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 194 Original policy
0630UOncology (breast), mRNA, gene expression profiling by microarray of 80 genes (80 content and 465 housekeeping), utilizing formalin-fixed paraffin-embedded tissue (FFPE), algorithm reported as an index that is diagnostic of a molecular subtype (luminal, basal, Her2)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 195 Original policy
B4034Enter Feed Supkit Syr By Day2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 198 Original policy
B4035Enteral Feed Supp Pump Per D2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 198 Original policy
B4036Enteral Feed Sup Kit Grav By2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 198 Original policy
B4102Enteral Formula For Adults Used To Replace Fluids And Electrolytes (E.G. Clear Liquids) 500 Ml = 1 Unit2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 198 Original policy
B4103Enteral Formula For Pediatrics Used To Replace Fluids And Electrolytes (E.G. Clear Liquids) 500 Ml = 1 Unit2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 198 Original policy
B4104Additive For Enteral Formula (E.G. Fiber)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 198 Original policy
B4149Enteral Formula Manufactured Blenderized Natural Foods With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 198 Original policy
B4150Enteral Formula Nutritionally Complete With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 198 Original policy
B4152Enteral Formula Nutritionally Complete Calorically Dense (Equal To Or Greater Than 1. 5 Kcal/Ml) With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 199 Original policy
B4153Enteral Formula Nutritionally Complete Hydrolyzed Proteins (Amino Acids And Peptide Chain) Includes Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 199 Original policy
B4154Enteral Formula Nutritionally Complete For Special Metabolic Needs Excludes Inherited Disease Of Metabolism Includes Altered Composition Of Proteins Fats Carbohydrates Vitamins And/Or Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 199 Original policy
B4155Enteral Formula Nutritionally Incomplete/Modular Nutrients Includes Specific Nutrients Carbohydrates (E. G. Glucose Polymers) Proteins/Amino Acids (E. G. Glutamine Arginine) Fat (E. G. Medium Chain Triglycerides) Or Combination Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 199 Original policy
B4158Enteral Formula For Pediatrics Nutritionally Complete With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber And/Or Iron Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 200 Original policy
B4159Enteral Formula For Pediatrics Nutritionally Complete Soy Based With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber And/Or Iron Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 200 Original policy
B4160Enteral Formula For Pediatrics Nutritionally Complete Calorically Dense (Equal To Or Greater Than 0.7 Kcal/Ml) With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 200 Original policy
B4161Enteral Formula For Pediatrics Hydrolyzed/Amino Acids And Peptide Chain Proteins Includes Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 200 Original policy
B4164Parenteral Nutrition Solution: Carbohydrates (Dextrose) 50% Or Less (500 Ml = 1 Unit) - Homemix2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 200 Original policy
B4168Parenteral Nutrition Solution; Amino Acid 3. 5% (500 Ml = 1 Unit) - Homemix2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 200 Original policy
B4172Parenteral Nutrition Solution; Amino Acid 5. 5% Through 7% (500 Ml = 1 Unit) - Homemix2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 201 Original policy
B4176Parenteral Nutrition Solution; Amino Acid 7% Through 8. 5% (500 Ml = 1 Unit) - Homemix2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 201 Original policy
B4178Parenteral Nutrition Solution: Amino Acid Greater Than 8. 5% (500 Ml = 1 Unit) - Homemix2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 201 Original policy
B4180Parenteral Nutrition Solution; Carbohydrates (Dextrose) Greater Than 50% (500 Ml=1 Unit) - Homemix2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 201 Original policy
B4185Parenteral Nutrition Solution Not Otherwise Specified 10 Grams Lipids2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 201 Original policy
B4189Parenteral Nutrition Solution; Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength 10 To 51 Grams Of Protein - Premix2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 201 Original policy
B4193Parenteral Nutrition Solution; Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength 52 To 73 Grams Of Protein - Premix2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 201 Original policy
B4197Parenteral Nutrition Solution; Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength 74 To 100 Grams Of Protein - Premix2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 201 Original policy
B4199Parenteral Nutrition Solution; Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength Over 100 Grams Of Protein - Premix2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 202 Original policy
B4216Parenteral Nutrition; Additives (Vitamins Trace Elements Heparin Electrolytes) Homemix Per Day2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 202 Original policy
B4220Parenteral Nutrition Supply Kit; Premix Per Day2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 202 Original policy
B4222Parenteral Nutrition Supply Kit; Home Mix Per Day2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 202 Original policy
B4224Parenteral Nutrition Administration Kit Per Day2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 202 Original policy
B5000Parenteral Nutrition Solution Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength Renal-Aminosyn-Rf Nephramine Renamine-Premix2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 202 Original policy
B5100Parenteral Nutrition Solution Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength Hepatic Hepatamine- Premix2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 202 Original policy
B5200Parenteral Nutrition Solution Compounded Amino Acid And Carbohydrates With Electrolytes Trace Elements And Vitamins Including Preparation Any Strength Stress-Branch Chain Amino Acids-Freamine-Hbc-Premix2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 202 Original policy
B9002Enteral Nutrition Infusion Pump Any Type2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 202 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.

This website uses cookies to ensure you get the best experience on our website. Learn more