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Blue Cross Blue Shield Oklahoma prior authorization, page 34

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
64628Thermal destruction of intraosseous basivertebral nerve including all imaging guidance; first 2 vertebral bodies lumbar or sacral2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 240 Original policy
64640Destruction by neurolytic agent; other peripheral nerve or branch2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 240 Original policy
66174Transluminal dilation of aqueous outflow canal (eg, canaloplasty); without retention of device or stent2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 240 Original policy
67904Repair of blepharoptosis; (tarso) levator resection or advancement, external approach2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 240 Original policy
69705Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); unilateral2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 240 Original policy
69706Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); bilateral2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 240 Original policy
91110Gastrointestinal tract imaging intraluminal (eg capsule endoscopy) esophagus through ileum with interpretation and report2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 240 Original policy
93580Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 240 Original policy
93660Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 241 Original policy
95807Sleep Study Simultaneous Recording Of Ventilation Respiratory Effort Ecg Or Heart Rate And Oxygen Saturation Attended By A Technologist2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 241 Original policy
95808Polysomnography; Any Age Sleep Staging With 1- 3 Additional Parameters Of Sleep Attended By A Technologist2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 241 Original policy
95810Polysomnography; Age 6 Years Or Older Sleep Staging With 4 Or More Additional Parameters Of Sleep Attended By A Technologist2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 241 Original policy
95811Polysomnography; Age 6 Years Or Older Sleep Staging With 4 Or More Additional Parameters Of Sleep With Initiation Of Continuous Positive Airway Pressure Therapy Or Bilevel Ventilation Attended By A Technologist2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 241 Original policy
95972Electronic Analysis Of Implanted Neurostimulator Pulse Generator/Transmitter (Eg Contact Group[S] Interleaving Amplitude Pulse Width Frequency [Hz] On/Off Cycling Burst Magnet Mode Dose Lockout Patient Selectable Parameters Responsive Neurostimulation Detection Algorithms Closed Loop Parameters And Passive Parameters) By Physician Or Other Qualified Health Care Professional; With Complex Spinal Cord Or Peripheral Nerve (Eg Sacral Nerve) Neurostimulator Pulse Generator/Transmitter Programming By Physician Or Other Qualified Health Care Professional2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 242 Original policy
97533Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 242 Original policy
0071TFocused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 242 Original policy
0072TFocused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 242 Original policy
0253TInsertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal space2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 243 Original policy
0308TInsertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 243 Original policy
0345TTranscatheter mitral valve repair percutaneous approach via the coronary sinus2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 243 Original policy
0596TTemporary female intraurethral valve-pump (ie, voiding prosthesis); initial insertion, including urethral measurement2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 243 Original policy
0597TTemporary female intraurethral valve-pump (ie, voiding prosthesis); replacement2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 243 Original policy
C1605Pacemaker, leadless, dual chamber (right atrial and right ventricular implantable components), rate-responsive, including all necessary components for implantation2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 243 Original policy
C1734Orthopedic/device/drug matrix for opposing bone to-bone or soft tissue-to bone (implantable)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 243 Original policy
C1737Joint fusion and fixation device(s), sacroiliac and pelvis, including all system components (implantable)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 243 Original policy
C1764Event recorder, cardiac (implantable)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 243 Original policy
C1778Lead, neurostimulator (implantable)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 243 Original policy
C1817Septal defect implant system, intracardiac2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 243 Original policy
C1820Generator, neurostimulator (implantable), with rechargeable battery and charging system2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 244 Original policy
C1821Interspinous process distraction device (implantable)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 244 Original policy
C1822Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 244 Original policy
C1826Generator, neurostimulator (implantable), includes closed feedback loop leads and all implantable components, with rechargeable battery and charging system2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 244 Original policy
C1833Monitor, cardiac, including intracardiac lead and all system components (implantable)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 244 Original policy
C2616Brachytherapy source, non-stranded, yttrium-90, per source2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 244 Original policy
C2624Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 244 Original policy
C7504Percutaneous vertebroplasties (bone biopsies included when performed), first cervicothoracic and any additional cervicothoracic or lumbosacral vertebral bodies, unilateral or bilateral injection, inclusive of all imaging guidance2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 244 Original policy
C7505Percutaneous vertebroplasties (bone biopsies included when performed), first lumbosacral and any additional cervicothoracic or lumbosacral vertebral bodies, unilateral or bilateral injection, inclusive of all imaging guidance2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 244 Original policy
C7507Percutaneous vertebral augmentations, first thoracic and any additional thoracic or lumbar vertebral bodies, including cavity creations (fracture reductions and bone biopsies included when performed) using mechanical device (e.g., kyphoplasty), unilateral or bilateral cannulations, inclusive of all imaging guidance2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 245 Original policy
C7508Percutaneous vertebral augmentations, first lumbar and any additional thoracic or lumbar vertebral bodies, including cavity creations (fracture reductions and bone biopsies included when performed) using mechanical device (e.g., kyphoplasty), unilateral or bilateral cannulations, inclusive of all imaging guidance2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 245 Original policy
C9740Cystourethroscopy, with insertion of transprostatic implant; 4 or more implants2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 245 Original policy
C9785Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 245 Original policy
E0493Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by phone application, 90-day supply2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 245 Original policy
E0652Pneumatic compressor, segmental home model with calibrated gradient pressure2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 245 Original policy
E0673Segmental gradient pressure pneumatic appliance, half leg2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 245 Original policy
E0676Intermittent limb compression device (includes all accessories), not otherwise specified2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 246 Original policy
E0680Non-pneumatic compression controller with sequential calibrated gradient pressure2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 246 Original policy
E0739Rehabilitation system with interactive interface providing active assistance in rehabilitation therapy, includes all components and accessories, motors, microprocessors, sensors2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 246 Original policy
E0747Osteogenesis stimulator, electrical, non- invasive, other than spinal applications2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 246 Original policy
E0760Osteogenesis stimulator, low intensity ultrasound, non-invasive2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 246 Original policy
E0766Electrical stimulation device used for cancer treatment, includes all accessories, any type2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 246 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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