Premera Blue Cross of Washington prior authorization, page 11
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 |
|---|---|---|
| 29806 | Arthroscopy, shoulder, surgical; capsulorrhaphy These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 271 Original policy |
| 29807 | Arthroscopy, shoulder, surgical; repair of SLAP lesion | Clinical Review by Code List PBCWA, Pg 272 Original policy |
| 29819 | Arthroscopy, shoulder, surgical; with removal of loose body or foreign body | Clinical Review by Code List PBCWA, Pg 272 Original policy |
| 29820 | Arthroscopy, shoulder, surgical; synovectomy, partial | Clinical Review by Code List PBCWA, Pg 272 Original policy |
| 29821 | Arthroscopy, shoulder, surgical; synovectomy, complete These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 272 Original policy |
| 29824 | Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) | Clinical Review by Code List PBCWA, Pg 273 Original policy |
| 29825 | Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation | Clinical Review by Code List PBCWA, Pg 273 Original policy |
| 29826 | Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (i.e., arch) release, when performed (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 273 Original policy |
| 29827 | Arthroscopy, shoulder, surgical; with rotator cuff repair These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 273 Original policy |
| 29848 | Endoscopy, wrist, surgical, with release of transverse carpal ligament | Clinical Review by Code List PBCWA, Pg 274 Original policy |
| 29866 | Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) | Clinical Review by Code List PBCWA, Pg 274 Original policy |
| 29867 | Arthroscopy, knee, surgical; osteochrondral allograft(s) | Clinical Review by Code List PBCWA, Pg 274 Original policy |
| 29871 | Arthroscopy, knee, surgical; for infection, lavage and drainage These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 274 Original policy |
| 29873 | Arthroscopy, knee, surgical; with lateral release | Clinical Review by Code List PBCWA, Pg 275 Original policy |
| 29874 | Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) | Clinical Review by Code List PBCWA, Pg 275 Original policy |
| 29875 | Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure) | Clinical Review by Code List PBCWA, Pg 275 Original policy |
| 29876 | Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 275 Original policy |
| 29877 | Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) | Clinical Review by Code List PBCWA, Pg 276 Original policy |
| 29879 | Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture | Clinical Review by Code List PBCWA, Pg 276 Original policy |
| 29880 | Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) | Clinical Review by Code List PBCWA, Pg 276 Original policy |
| 29881 | Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 276 Original policy |
| 29882 | Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) | Clinical Review by Code List PBCWA, Pg 277 Original policy |
| 29883 | Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) | Clinical Review by Code List PBCWA, Pg 277 Original policy |
| 29884 | Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure) | Clinical Review by Code List PBCWA, Pg 277 Original policy |
| 29888 | Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 277 Original policy |
| 29889 | Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction | Clinical Review by Code List PBCWA, Pg 278 Original policy |
| 29914 | Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) | Clinical Review by Code List PBCWA, Pg 278 Original policy |
| 29915 | Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion) | Clinical Review by Code List PBCWA, Pg 278 Original policy |
| 30400 | Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 278 Original policy |
| 30410 | Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip | Clinical Review by Code List PBCWA, Pg 279 Original policy |
| 30420 | Rhinoplasty, primary; including major septal repair | Clinical Review by Code List PBCWA, Pg 279 Original policy |
| 30430 | Rhinoplasty, secondary; minor revision (small amount of nasal tip work) | Clinical Review by Code List PBCWA, Pg 279 Original policy |
| 30435 | Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) | Clinical Review by Code List PBCWA, Pg 279 Original policy |
| 30450 | Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 279 Original policy |
| 31253 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed | Clinical Review by Code List PBCWA, Pg 281 Original policy |
| 31254 | Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) | Clinical Review by Code List PBCWA, Pg 281 Original policy |
| 31255 | Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior) | Clinical Review by Code List PBCWA, Pg 281 Original policy |
| 31256 | Nasal/sinus endoscopy, surgical, with maxillary antrostomy; These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 281 Original policy |
| 31257 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy | Clinical Review by Code List PBCWA, Pg 282 Original policy |
| 31259 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus | Clinical Review by Code List PBCWA, Pg 282 Original policy |
| 31267 | Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus | Clinical Review by Code List PBCWA, Pg 282 Original policy |
| 31276 | Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 282 Original policy |
| 31287 | Nasal/sinus endoscopy, surgical, with sphenoidotomy | Clinical Review by Code List PBCWA, Pg 283 Original policy |
| 31288 | Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus | Clinical Review by Code List PBCWA, Pg 283 Original policy |
| 31295 | Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium transnasal or via canine fossa These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 283 Original policy |
| 31296 | Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium | Clinical Review by Code List PBCWA, Pg 284 Original policy |
| 31297 | Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation) sphenoid sinus ostium | Clinical Review by Code List PBCWA, Pg 284 Original policy |
| 31298 | Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation) frontal and sphenoid sinus ostia | Clinical Review by Code List PBCWA, Pg 284 Original policy |
| 31643 | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of catheter(s) for intracavitary radioelement application | Clinical Review by Code List PBCWA, Pg 285 Original policy |
| 32664 | Thoracoscopy, surgical; with thoracic sympathectomy | Clinical Review by Code List PBCWA, Pg 286 Original policy |