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Blue Cross Blue Shield Oklahoma prior authorization, page 36

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
L5978All lower extremity prostheses, foot, multiaxial ankle/foot2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 251 Original policy
L6648Upper extremity addition, shoulder lock mechanism, external powered actuator2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 251 Original policy
L6715Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 251 Original policy
L6885Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 251 Original policy
L6920Wrist disarticulation, external power, self- suspended inner socket, removable forearm shell, otto bock or equal, switch, cables, two batteries and one charger, switch control of terminal device2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 251 Original policy
L6945Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 252 Original policy
L6960Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 252 Original policy
L6970Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 252 Original policy
L6975Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 252 Original policy
L7040Prehensile actuator, switch controlled2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 252 Original policy
L7045Electric hook, switch or myoelectric controlled, pediatric2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 252 Original policy
L7170Electronic elbow, hosmer or equal, switch controlled2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 252 Original policy
L7185Electronic elbow, adolescent, variety village or equal, switch controlled2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 253 Original policy
L7186Electronic elbow, child, variety village or equal, switch controlled2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 253 Original policy
L7190Electronic elbow, adolescent, variety village or equal, myoelectronically controlled2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 253 Original policy
L7191Electronic elbow, child, variety village or equal, myoelectronically controlled2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 253 Original policy
L7360Six volt battery, each2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 253 Original policy
L8679Implantable neurostimulator, pulse generator, any type2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 253 Original policy
L8680Implantable neurostimulator electrode, each2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 253 Original policy
L8685Implantable neurostimulator pulse generator, single array, rechargeable, includes extension2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 253 Original policy
L8686Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 253 Original policy
L8687Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 253 Original policy
L8688Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 253 Original policy
L8701Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 254 Original policy
L8702Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 254 Original policy
Q4116Alloderm, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 254 Original policy
Q4122Dermacell, dermacell awm or dermacell awm porous, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 254 Original policy
Q4128Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 254 Original policy
Q4133Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 254 Original policy
Q4158Kerecis omega3, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 254 Original policy
Q4159Affinity, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 254 Original policy
Q4186Epifix, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 254 Original policy
Q4226Myown skin, includes harvesting and preparation procedures, per square centimeter2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
Q4392Grafix duo, per square centimeter (add-on, list separately in addition to primary procedure)2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
S0215Non-emergency transportation; mileage, per mile2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
S9988Services provided as part of a phase i clinical trial2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
S9990Services provided as part of a phase ii clinical trial2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
S9991Services provided as part of a phase iii clinical trial2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
0660UHPV GNOTYP 18/31/33/35 CFDNA2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
0661UHPV GENOTYPE 16 CFDNA DDPCR2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
0662UTRNSPLJ MED KAR RTQPCR 12GEN2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
0663UOB FETAL PLTLT AG NIPT CFDNA2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
0664UTRNSPLJ MED KAF NGS 13 GENES2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
0668UONC PNCRS DNA 5HMC & GLYCAN2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
0670URARE DS WGSA S/L READ CMPRTR2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
0671URARE DS WGSA S/L RD 2CMPRTRS2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
0672URARE DS WHOLE EXOME CMPRTR2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 255 Original policy
0673URARE DS WHOLE EXOME 2CMPRTRS2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 256 Original policy
0674URARE DS MTDNA BLD/SLV/GENDNA2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 256 Original policy
0675URARE DS MTDNA PRBND&2CMPRTRS2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 256 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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