Premera Blue Cross of Washington prior authorization, page 12
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 |
|---|---|---|
| 32701 | Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment | Clinical Review by Code List PBCWA, Pg 286 Original policy |
| 32851 | Lung transplant, single; without cardiopulmonary bypass | Clinical Review by Code List PBCWA, Pg 286 Original policy |
| 32852 | Lung transplant, single; with cardiopulmonary bypass | Clinical Review by Code List PBCWA, Pg 286 Original policy |
| 32853 | Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass | Clinical Review by Code List PBCWA, Pg 286 Original policy |
| 32854 | Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 286 Original policy |
| 32994 | Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation | Clinical Review by Code List PBCWA, Pg 287 Original policy |
| 32998 | Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; radiofrequency | Clinical Review by Code List PBCWA, Pg 287 Original policy |
| 33216 | Insertion of a single transvenous electrode, permanent pacemaker or implantable defibrillator | Clinical Review by Code List PBCWA, Pg 287 Original policy |
| 33217 | Insertion of 2 transvenous electrodes, permanent pacemaker or implantable defibrillator | Clinical Review by Code List PBCWA, Pg 287 Original policy |
| 33230 | Insertion of pacing cardioverter-defibrillator pulse generator only; with existing dual leads | Clinical Review by Code List PBCWA, Pg 287 Original policy |
| 33231 | Insertion of implantable defibrillator pulse generator only; with existing multiple leads These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 287 Original policy |
| 33240 | Insertion of implantable defibrillator pulse generator only; with existing single lead | Clinical Review by Code List PBCWA, Pg 288 Original policy |
| 33249 | Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator | Clinical Review by Code List PBCWA, Pg 288 Original policy |
| 33254 | Operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure) | Clinical Review by Code List PBCWA, Pg 288 Original policy |
| 33255 | Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); without cardiopulmonary bypass | Clinical Review by Code List PBCWA, Pg 288 Original policy |
| 33256 | Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); with cardiopulmonary bypass | Clinical Review by Code List PBCWA, Pg 288 Original policy |
| 33258 | Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), without cardiopulmonary bypass (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 288 Original policy |
| 33265 | Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure), without cardiopulmonary bypass | Clinical Review by Code List PBCWA, Pg 288 Original policy |
| 33266 | Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure), without cardiopulmonary bypass These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 288 Original policy |
| 33270 | Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed | Clinical Review by Code List PBCWA, Pg 289 Original policy |
| 33271 | Insertion of subcutaneous implantable defibrillator electrode These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 289 Original policy |
| 33274 | Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed | Clinical Review by Code List PBCWA, Pg 290 Original policy |
| 33285 | Insertion, subcutaneous cardiac rhythm monitor, including programming | Clinical Review by Code List PBCWA, Pg 290 Original policy |
| 33340 | Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation | Clinical Review by Code List PBCWA, Pg 290 Original policy |
| 33361 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 290 Original policy |
| 33362 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach | Clinical Review by Code List PBCWA, Pg 291 Original policy |
| 33363 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach | Clinical Review by Code List PBCWA, Pg 291 Original policy |
| 33364 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach | Clinical Review by Code List PBCWA, Pg 291 Original policy |
| 33365 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy) | Clinical Review by Code List PBCWA, Pg 291 Original policy |
| 33366 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical exposure (eg, left thoracotomy) | Clinical Review by Code List PBCWA, Pg 291 Original policy |
| 33418 | Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 291 Original policy |
| 33419 | Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 292 Original policy |
| 33477 | Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed | Clinical Review by Code List PBCWA, Pg 292 Original policy |
| 33927 | Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy | Clinical Review by Code List PBCWA, Pg 292 Original policy |
| 33928 | Removal and replacement of total replacement heart system (artificial heart) | Clinical Review by Code List PBCWA, Pg 292 Original policy |
| 33929 | Removal of a total replacement heart system (artificial heart) for heart transplantation (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 292 Original policy |
| 33935 | Heart-lung transplant with recipient cardiectomy- pneumonectomy | Clinical Review by Code List PBCWA, Pg 292 Original policy |
| 33945 | Heart transplant, with or without recipient cardiectomy | Clinical Review by Code List PBCWA, Pg 292 Original policy |
| 33975 | Insertion of ventricular assist device; extracorporeal, single ventricle | Clinical Review by Code List PBCWA, Pg 292 Original policy |
| 33976 | Insertion of ventricular assist device; extracorporeal, biventricular These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 292 Original policy |
| 33979 | Insertion of ventricular assist device implantable intracorporeal single ventricle | Clinical Review by Code List PBCWA, Pg 293 Original policy |
| 33981 | Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump | Clinical Review by Code List PBCWA, Pg 293 Original policy |
| 33982 | Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass | Clinical Review by Code List PBCWA, Pg 293 Original policy |
| 33983 | Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass | Clinical Review by Code List PBCWA, Pg 293 Original policy |
| 34701 | Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the aortic bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the aortic bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 294 Original policy |
| 34702 | Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the aortic bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the aortic bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption) | Clinical Review by Code List PBCWA, Pg 295 Original policy |
| 34703 | Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft including pre- procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 295 Original policy |
| 34704 | Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft including pre- procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption) | Clinical Review by Code List PBCWA, Pg 296 Original policy |
| 34705 | Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre- procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 296 Original policy |
| 34706 | Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre- procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption) | Clinical Review by Code List PBCWA, Pg 297 Original policy |