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Blue Cross Blue Shield Oklahoma prior authorization, page 33

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
43281Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of me2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 235 Original policy
43284Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 235 Original policy
43632Gastrectomy, partial, distal; with gastrojejunostomy2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 235 Original policy
43633Gastrectomy, partial, distal; with Roux-en-Y reconstruction2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 235 Original policy
43634Gastrectomy, partial, distal; with formation of intestinal pouch2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 235 Original policy
43644Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 235 Original policy
43645Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 235 Original policy
43770Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 235 Original policy
43771Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 236 Original policy
43772Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 236 Original policy
43773Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 236 Original policy
43774Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 236 Original policy
43775Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 236 Original policy
43842Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 236 Original policy
43843Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical- banded gastroplasty2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 236 Original policy
43845Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 236 Original policy
43846Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 237 Original policy
43847Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 237 Original policy
43848Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 237 Original policy
43860Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 237 Original policy
43865Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 237 Original policy
43889Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG), including argon plasma coagulation, when performed2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 237 Original policy
47382Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 237 Original policy
47384Ablation, irreversible electroporation, liver, 1 or more tumors, including imaging guidance, percutaneous2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 237 Original policy
50592Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 237 Original policy
52442Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 238 Original policy
54125Amputation of penis; complete2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 238 Original policy
54400Insertion of penile prosthesis; non-inflatable (semi-rigid)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 238 Original policy
54401Insertion of penile prosthesis; inflatable (self- contained)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 238 Original policy
54405Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 238 Original policy
54410Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 238 Original policy
54411Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 238 Original policy
54416Removal and replacement of non-inflatable (semi rigid) or inflatable (self-contained) penile prosthesis at the same operative session2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 238 Original policy
54417Removal and replacement of non-inflatable (semi rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 238 Original policy
54660Insertion of testicular prosthesis (separate procedure)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
55970Intersex surgery; male to female2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
55980Intersex surgery; female to male2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
56805Clitoroplasty for intersex state2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
56810Perineoplasty, repair of perineum, nonobstetrical (separate procedure)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
57291Construction of artificial vagina; without graft2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
57292Construction of artificial vagina; with graft2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
57295Revision (including removal) of prosthetic vaginal graft, vaginal approach2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
57296Revision (including removal) of prosthetic vaginal graft; open abdominal approach2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
57335Vaginoplasty for intersex state2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
57426Revision (including removal) of prosthetic vaginal graft, laparoscopic approach2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
64568Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
64575Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
64580Open Implantation Of Neurostimulator Electrode Array; Neuromuscular2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 239 Original policy
64590Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 240 Original policy
64624Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 240 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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