Premera Blue Cross of Washington prior authorization, page 13
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 |
|---|---|---|
| 34707 | Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 297 Original policy |
| 34708 | Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, traumatic disruption) | Clinical Review by Code List PBCWA, Pg 298 Original policy |
| 34709 | Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre- procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed, per vessel treated (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 298 Original policy |
| 34710 | Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed; initial vessel treated | Clinical Review by Code List PBCWA, Pg 299 Original policy |
| 34711 | Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed; each additional vessel treated (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 299 Original policy |
| 34717 | Endovascular repair of iliac artery at the time of aorto-iliac artery endograft placement by deployment of an iliac branched endograft including pre- procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally in the internal iliac, external iliac, and common femoral artery(ies), and treatment zone angioplasty/stenting, when performed, for rupture or other than rupture (e.g., for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, penetrating ulcer, traumatic disruption), unilateral (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 300 Original policy |
| 34718 | Endovascular repair of iliac artery, not associated with placement of an aorto-iliac artery endograft at the same session, by deployment of an iliac branched endograft, including pre-procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally in the internal iliac, external iliac, and common femoral artery(ies), and treatment zone angioplasty/stenting, when performed, for other than rupture (e.g., for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, penetrating ulcer), unilateral | Clinical Review by Code List PBCWA, Pg 301 Original policy |
| 34841 | Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 301 Original policy |
| 34842 | Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) | Clinical Review by Code List PBCWA, Pg 302 Original policy |
| 34843 | Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 302 Original policy |
| 34844 | Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) | Clinical Review by Code List PBCWA, Pg 303 Original policy |
| 34845 | Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 303 Original policy |
| 34846 | Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) | Clinical Review by Code List PBCWA, Pg 304 Original policy |
| 34847 | Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 304 Original policy |
| 34848 | Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) | Clinical Review by Code List PBCWA, Pg 305 Original policy |
| 36465 | Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein) | Clinical Review by Code List PBCWA, Pg 306 Original policy |
| 36466 | Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg | Clinical Review by Code List PBCWA, Pg 306 Original policy |
| 36468 | Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk | Clinical Review by Code List PBCWA, Pg 306 Original policy |
| 36470 | Injection of sclerosing solution; single vein | Clinical Review by Code List PBCWA, Pg 306 Original policy |
| 36471 | Injection of sclerosing solution; multiple veins, same leg | Clinical Review by Code List PBCWA, Pg 306 Original policy |
| 36475 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency,; first vein treated | Clinical Review by Code List PBCWA, Pg 307 Original policy |
| 36476 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites | Clinical Review by Code List PBCWA, Pg 307 Original policy |
| 36478 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated | Clinical Review by Code List PBCWA, Pg 307 Original policy |
| 36479 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 307 Original policy |
| 36482 | Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated | Clinical Review by Code List PBCWA, Pg 308 Original policy |
| 36483 | Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure | Clinical Review by Code List PBCWA, Pg 308 Original policy |
| 36511 | Therapeutic apheresis; for white blood cells | Clinical Review by Code List PBCWA, Pg 308 Original policy |
| 36522 | Photopheresis, extracorporeal | Clinical Review by Code List PBCWA, Pg 308 Original policy |
| 37243 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 308 Original policy |
| 37254 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 309 Original policy |
| 37255 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 309 Original policy |
| 37256 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 310 Original policy |
| 37257 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 310 Original policy |
| 37258 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform stent placement and angioplasty, when performed, within the same artery, unilateral; straightforward lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 311 Original policy |
| 37259 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform stent placement and angioplasty, when performed, within the same artery, unilateral; straightforward lesion, each addition vessel (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 311 Original policy |
| 37260 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform stent placement and angioplasty, when performed, within the same artery, unilateral; complex lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 312 Original policy |
| 37261 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform stent placement and angioplasty, when performed, within the same artery, unilateral; complex lesion, each addition vessel (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 312 Original policy |
| 37263 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 313 Original policy |
| 37264 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 313 Original policy |
| 37265 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 314 Original policy |
| 37266 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 314 Original policy |
| 37267 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform stent placement and angioplasty, when performed, within the same artery, unilateral; straightforward lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 315 Original policy |
| 37268 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform stent placement and angioplasty, when performed, within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to primary code) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 315 Original policy |
| 37269 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform stent placement and angioplasty, when performed, within the same artery, unilateral; complex lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 316 Original policy |
| 37270 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform stent placement and angioplasty, when performed, within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to primary code) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 316 Original policy |
| 37271 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty, when performed, within the same artery, unilateral; straightforward lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 317 Original policy |
| 37272 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty, when performed, within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to primary code) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 317 Original policy |
| 37273 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty, when performed, within the same artery, unilateral; complex lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 318 Original policy |
| 37274 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty, when performed, within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to primary code) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 318 Original policy |
| 37275 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement, atherectomy and angioplasty, when performed, within the same artery, unilateral; straightforward lesion, initial vessel These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 319 Original policy |