Premera Blue Cross of Washington prior authorization, page 10
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
| Code | Description | Source |
|---|---|---|
| 22858 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 260 Original policy |
| 22860 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 261 Original policy |
| 22861 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical | Clinical Review by Code List PBCWA, Pg 261 Original policy |
| 22862 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar | Clinical Review by Code List PBCWA, Pg 261 Original policy |
| 22865 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar | Clinical Review by Code List PBCWA, Pg 261 Original policy |
| 23105 | Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy | Clinical Review by Code List PBCWA, Pg 262 Original policy |
| 23106 | Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy | Clinical Review by Code List PBCWA, Pg 262 Original policy |
| 23120 | Claviculectomy; partial These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 262 Original policy |
| 23130 | Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release | Clinical Review by Code List PBCWA, Pg 263 Original policy |
| 23410 | Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute | Clinical Review by Code List PBCWA, Pg 263 Original policy |
| 23412 | Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic | Clinical Review by Code List PBCWA, Pg 263 Original policy |
| 23420 | Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) | Clinical Review by Code List PBCWA, Pg 263 Original policy |
| 23450 | Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation | Clinical Review by Code List PBCWA, Pg 263 Original policy |
| 23455 | Capsulorrhaphy, anterior; with labral repair (e.g., Bankart procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 263 Original policy |
| 23460 | Capsulorrhaphy, anterior, any type; with bone block | Clinical Review by Code List PBCWA, Pg 264 Original policy |
| 23462 | Capsulorrhaphy, anterior, any type; with coracoid process transfer | Clinical Review by Code List PBCWA, Pg 264 Original policy |
| 23465 | Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block | Clinical Review by Code List PBCWA, Pg 264 Original policy |
| 23466 | Capsulorrhaphy, glenohumeral joint, any type multi-directional instability | Clinical Review by Code List PBCWA, Pg 264 Original policy |
| 23470 | Arthroplasty, glenohumeral joint; hemiarthroplasty | Clinical Review by Code List PBCWA, Pg 264 Original policy |
| 23472 | Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) | Clinical Review by Code List PBCWA, Pg 264 Original policy |
| 23473 | Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component | Clinical Review by Code List PBCWA, Pg 264 Original policy |
| 23474 | Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 264 Original policy |
| 23550 | Open treatment of acromioclavicular dislocation, acute or chronic | Clinical Review by Code List PBCWA, Pg 265 Original policy |
| 23552 | Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) | Clinical Review by Code List PBCWA, Pg 265 Original policy |
| 23660 | Open treatment of acute shoulder dislocation | Clinical Review by Code List PBCWA, Pg 265 Original policy |
| 23670 | Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes internal fixation, when performed | Clinical Review by Code List PBCWA, Pg 265 Original policy |
| 23680 | Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes internal fixation, when performed | Clinical Review by Code List PBCWA, Pg 265 Original policy |
| 27130 | Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft | Clinical Review by Code List PBCWA, Pg 266 Original policy |
| 27132 | Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft | Clinical Review by Code List PBCWA, Pg 266 Original policy |
| 27134 | Revision of total hip arthroplasty; both components, with or without autograft or allograft | Clinical Review by Code List PBCWA, Pg 266 Original policy |
| 27137 | Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 266 Original policy |
| 27138 | Revision of total hip arthroplasty; femoral component only, with or without allograft | Clinical Review by Code List PBCWA, Pg 267 Original policy |
| 27279 | Arthrodesis, sacroiliac joint, percutaneous or minimally invasive, with image guidance, includes obtaining bone graft when performed, unilateral; placement of transarticular device(s) and/or intra-articular device(s) piercing the lateral or medial cortices of the ilium and the lateral cortex of the sacrum | Clinical Review by Code List PBCWA, Pg 267 Original policy |
| 27280 | Arthrodesis, sacroiliac joint, open, includes obtaining bone graft, including instrumentation, when performed | Clinical Review by Code List PBCWA, Pg 267 Original policy |
| 27412 | Autologous chondrocyte implantation, knee | Clinical Review by Code List PBCWA, Pg 268 Original policy |
| 27415 | Osteochrondral allograft, knee, open | Clinical Review by Code List PBCWA, Pg 268 Original policy |
| 27416 | Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) | Clinical Review by Code List PBCWA, Pg 268 Original policy |
| 27440 | Arthroplasty, knee, tibial plateau | Clinical Review by Code List PBCWA, Pg 268 Original policy |
| 27441 | Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy | Clinical Review by Code List PBCWA, Pg 268 Original policy |
| 27442 | Arthroplasty, femoral condyles or tibial plateau(s), knee | Clinical Review by Code List PBCWA, Pg 268 Original policy |
| 27443 | Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy | Clinical Review by Code List PBCWA, Pg 268 Original policy |
| 27446 | Arthroplasty, knee, condyle and plateau; medial OR lateral compartment These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 268 Original policy |
| 27447 | Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) | Clinical Review by Code List PBCWA, Pg 269 Original policy |
| 27486 | Revision of total knee arthroplasty, with or without allograft; 1 component | Clinical Review by Code List PBCWA, Pg 269 Original policy |
| 27487 | Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component | Clinical Review by Code List PBCWA, Pg 269 Original policy |
| 27700 | Arthroplasty, ankle | Clinical Review by Code List PBCWA, Pg 269 Original policy |
| 27702 | Arthroplasty, ankle; with implant (total ankle) | Clinical Review by Code List PBCWA, Pg 269 Original policy |
| 27703 | Arthroplasty, ankle; revision, total ankle These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 269 Original policy |
| 28291 | Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant | Clinical Review by Code List PBCWA, Pg 270 Original policy |
| 28446 | Open osteochondral autograft, talus (includes obtaining graft[s]) | Clinical Review by Code List PBCWA, Pg 270 Original policy |