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Blue Cross Blue Shield Oklahoma prior authorization, page 5

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
0042TCerebral Perfusion Analysis Using Computed Tomography With Contrast Administration Including Post-Processing Of Parametric Maps With Determination Of Cerebral Blood Flow Cerebral Blood Volume And Mean Transit Time2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 22 Original policy
0633TComputed Tomography Breast Including 3D Rendering When Performed Unilateral; Without Contrast Material2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 22 Original policy
0634TComputed Tomography Breast Including 3D Rendering When Performed Unilateral; With Contrast Material(S)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 22 Original policy
0635TComputed Tomography Breast Including 3D Rendering When Performed Unilateral; Without Contrast Followed By Contrast Material(S)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 22 Original policy
0636TComputed Tomography Breast Including 3D Rendering When Performed Bilateral; Without Contrast Material(S)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 23 Original policy
0637TComputed Tomography Breast Including 3D Rendering When Performed Bilateral; With Contrast Material(S)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 23 Original policy
0638TComputed Tomography Breast Including 3D Rendering When Performed Bilateral; Without Contrast Followed By Contrast Material(S)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 23 Original policy
0648TQuantitative Magnetic Resonance For Analysis Of Tissue Composition (Eg Fat Iron Water Content) Including Multiparametric Data Acquisition Data Preparation And Transmission Interpretation And Report Obtained Without Diagnostic Mri Examination Of The Same Anatomy (Eg Organ Gland Tissue Target Structure) During The Same Session; Single Organ2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 23 Original policy
0649TQuantitative Magnetic Resonance For Analysis Of Tissue Composition (Eg Fat Iron Water Content) Including Multiparametric Data Acquisition Data Preparation And Transmission Interpretation And Report Obtained With Diagnostic Mri Examination Of The Same Anatomy (Eg Organ Gland Tissue Target Structure); Single Organ (List Separately In Addition To Code For Primary Procedure)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 23 Original policy
A9602Fluorodopa F-18 Diagnostic Per Millicurie2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 23 Original policy
A9800Gallium Ga-68 Gozetotide Diagnostic (Locametz) 1 Millicurie2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 24 Original policy
C8900Magnetic Resonance Angiography With Contrast Abdomen2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 24 Original policy
C8901Magnetic Resonance Angiography Without Contrast Abdomen2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 24 Original policy
C8902Magnetic Resonance Angiography Without Contrast Followed By With Contrast Abdomen2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 24 Original policy
C8903Magnetic Resonance Imaging With Contrast Breast; Unilateral2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 24 Original policy
C8905Magnetic Resonance Imaging Without Contrast Followed By With Contrast Breast; Unilateral2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 24 Original policy
C8906Magnetic Resonance Imaging With Contrast Breast; Bilateral2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 24 Original policy
C8908Magnetic Resonance Imaging Without Contrast Followed By With Contrast Breast; Bilateral2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 24 Original policy
C8909Magnetic Resonance Angiography With Contrast Chest (Excluding Myocardium)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 24 Original policy
C8910Magnetic Resonance Angiography Without Contrast Chest (Excluding Myocardium)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 24 Original policy
C8911Magnetic Resonance Angiography Without Contrast Followed By With Contrast Chest (Excluding Myocardium)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 24 Original policy
C8912Magnetic Resonance Angiography With Contrast Lower Extremity2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 24 Original policy
C8913Magnetic Resonance Angiography Without Contrast Lower Extremity2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 24 Original policy
C8914Magnetic Resonance Angiography Without Contrast Followed By With Contrast Lower Extremity2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 25 Original policy
C8918Magnetic Resonance Angiography With Contrast Pelvis2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 25 Original policy
C8919Magnetic Resonance Angiography Without Contrast Pelvis2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 25 Original policy
C8920Magnetic Resonance Angiography Without Contrast Followed By With Contrast Pelvis2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 25 Original policy
C8931Magnetic Resonance Angiography With Contrast Spinal Canal And Contents2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 25 Original policy
C8932Magnetic Resonance Angiography Without Contrast Spinal Canal And Contents2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 25 Original policy
C8933Magnetic Resonance Angiography Without Contrast Followed By With Contrast Spinal Canal And Contents2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 25 Original policy
C8934Magnetic Resonance Angiography With Contrast Upper Extremity2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 25 Original policy
C8935Magnetic Resonance Angiography Without Contrast Upper Extremity2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 25 Original policy
C8936Magnetic Resonance Angiography Without Contrast Followed By With Contrast Upper Extremity2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 25 Original policy
G0219Pet Imaging Whole Body; Melanoma For Non-Covered Indications2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 25 Original policy
G0235Pet Imaging Any Site Not Otherwise Specified2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 25 Original policy
G0252Pet Imaging Full And Partial-Ring Pet Scanners Only For Initial Diagnosis Of Breast Cancer And/Or Surgical Planning For Breast Cancer (E. G. Initial Staging Of Axillary Lymph Nodes)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 26 Original policy
S8037Magnetic Resonance Cholangiopancreatography (Mrcp)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 26 Original policy
75557Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 26 Original policy
75559Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material; With Stress Imaging2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 26 Original policy
75561Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material(S) Followed By Contrast Material(S) And Further Sequences2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 26 Original policy
75563Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material(S) Followed By Contrast Material(S) And Further Sequences; With Stress Imaging2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 26 Original policy
75565Cardiac Magnetic Resonance Imaging For Velocity Flow Mapping (List Separately In Addition To Code For Primary Procedure)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 26 Original policy
75571Computed Tomography Heart Without Contrast Material With Quantitative Evaluation Of Coronary Calcium2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 26 Original policy
75572Computed Tomography Heart With Contrast Material For Evaluation Of Cardiac Structure And Morphology (Including 3D Image Postprocessing Assessment Of Cardiac Function And Evaluation Of Venous Structures If Performed)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 27 Original policy
75573Computed Tomography Heart With Contrast Material For Evaluation Of Cardiac Structure And Morphology In The Setting Of Congenital Heart Disease (Including 3D Image Postprocessing Assessment Of Left Ventricular [Lv] Cardiac Function Right Ventricular [Rv] Structure And Function And Evaluation Of Vascular Structures If Performed)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 27 Original policy
75574Computed Tomographic Angiography Heart Coronary Arteries And Bypass Grafts (When Present) With Contrast Material Including 3D Image Postprocessing (Including Evaluation Of Cardiac Structure And Morphology Assessment Of Cardiac Function And Evaluation Of Venous Structures If Performed)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 27 Original policy
78429Myocardial Imaging Positron Emission Tomography (Pet) Metabolic Evaluation Study (Including Ventricular Wall Motion[S] And/Or Ejection Fraction[S] When Performed) Single Study; With Concurrently Acquired Computed Tomography Transmission Scan2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 27 Original policy
78430Myocardial Imaging Positron Emission Tomography (Pet) Perfusion Study (Including Ventricular Wall Motion[S] And/Or Ejection Fraction[S] When Performed); Single Study At Rest Or Stress (Exercise Or Pharmacologic) With Concurrently Acquired Computed Tomography Transmission Scan2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 28 Original policy
78431Myocardial Imaging Positron Emission Tomography (Pet) Perfusion Study (Including Ventricular Wall Motion[S] And/Or Ejection Fraction[S] When Performed); Multiple Studies At Rest And Stress (Exercise Or Pharmacologic) With Concurrently Acquired Computed Tomography Transmission Scan2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 28 Original policy
78432Myocardial Imaging Positron Emission Tomography (Pet) Combined Perfusion With Metabolic Evaluation Study (Including Ventricular Wall Motion[S] And/Or Ejection Fraction[S] When Performed) Dual Radiotracer (Eg Myocardial Viability)2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 28 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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