Premera Blue Cross of Washington prior authorization, page 14
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 |
|---|---|---|
| 37276 | 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, each additional vessel (List separately in addition to primary code) | Clinical Review by Code List PBCWA, Pg 320 Original policy |
| 37277 | 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; complex lesion, initial vessel These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 320 Original policy |
| 37278 | 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; complex lesion, each additional vessel (List separately in addition to primary code) | Clinical Review by Code List PBCWA, Pg 321 Original policy |
| 37280 | Revascularization, endovascular, open or percutaneous, tibial and peroneal 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 322 Original policy |
| 37281 | Revascularization, endovascular, open or percutaneous, tibial and peroneal 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 322 Original policy |
| 37282 | Revascularization, endovascular, open or percutaneous, tibial and peroneal 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 323 Original policy |
| 37283 | Revascularization, endovascular, open or percutaneous, tibial and peroneal 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 323 Original policy |
| 37284 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including 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 stent placement and angioplasty within the same artery, unilateral; straightforward lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 324 Original policy |
| 37285 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including 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 stent placement and 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 324 Original policy |
| 37286 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including 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 stent placement and angioplasty within the same artery, unilateral; complex lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 325 Original policy |
| 37287 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including 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 stent placement and 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 325 Original policy |
| 37288 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including 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 atherectomy and angioplasty within the same artery, unilateral; straightforward lesion, initial vessel) | Clinical Review by Code List PBCWA, Pg 326 Original policy |
| 37289 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including 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 atherectomy and 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 326 Original policy |
| 37290 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including 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 atherectomy and angioplasty within the same artery, unilateral; complex lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 327 Original policy |
| 37291 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including 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 atherectomy, and 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 327 Original policy |
| 37292 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including 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 stent placement, atherectomy, and angioplasty within the same artery, unilateral; straightforward lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 328 Original policy |
| 37293 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including 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 stent placement, atherectomy, and 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 328 Original policy |
| 37294 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including 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 stent placement, atherectomy, and angioplasty within the same artery, unilateral; complex lesion, initial vessel | Clinical Review by Code List PBCWA, Pg 329 Original policy |
| 37295 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including 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 stent placement, atherectomy, and 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 329 Original policy |
| 37296 | Revascularization, endovascular, open or percutaneous, inframalleolar 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 330 Original policy |
| 37297 | Revascularization, endovascular, open or percutaneous, inframalleolar 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 These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 330 Original policy |
| 37298 | Revascularization, endovascular, open or percutaneous inframalleolar 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 331 Original policy |
| 37299 | Revascularization, endovascular, open or percutaneous, inframalleolar 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) | Clinical Review by Code List PBCWA, Pg 331 Original policy |
| 38228 | Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous | Clinical Review by Code List PBCWA, Pg 332 Original policy |
| 38230 | Bone marrow harvesting for transplantation; allogeneic | Clinical Review by Code List PBCWA, Pg 332 Original policy |
| 38232 | Bone marrow harvesting for transplantation; autologous | Clinical Review by Code List PBCWA, Pg 332 Original policy |
| 38240 | Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor | Clinical Review by Code List PBCWA, Pg 332 Original policy |
| 38241 | Hematopoietic progenitor cell (HPC); autologous transplantation | Clinical Review by Code List PBCWA, Pg 332 Original policy |
| 40500 | Vermilionectomy (lip shave), with mucosal advancement | Clinical Review by Code List PBCWA, Pg 333 Original policy |
| 40510 | Excision of lip; transverse wedge excision with primary closure | Clinical Review by Code List PBCWA, Pg 333 Original policy |
| 40520 | Excision of lip; V-excision with primary direct linear closure These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 333 Original policy |
| 40525 | Excision of lip; full thickness, reconstruction with local flap (eg, Estlander or fan) | Clinical Review by Code List PBCWA, Pg 334 Original policy |
| 40527 | Excision of lip; full thickness, reconstruction with cross lip flap (Abbe-Estlander) | Clinical Review by Code List PBCWA, Pg 334 Original policy |
| 41019 | Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application | Clinical Review by Code List PBCWA, Pg 335 Original policy |
| 41512 | Tongue base suspension, permanent suture technique | Clinical Review by Code List PBCWA, Pg 335 Original policy |
| 41530 | Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session | Clinical Review by Code List PBCWA, Pg 335 Original policy |
| 42145 | Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 335 Original policy |
| 42950 | Pharyngoplasty (plastic or reconstructive operation on pharynx) | Clinical Review by Code List PBCWA, Pg 336 Original policy |
| 43201 | Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance | Clinical Review by Code List PBCWA, Pg 336 Original policy |
| 43210 | Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 336 Original policy |
| 43235 | Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | Clinical Review by Code List PBCWA, Pg 337 Original policy |
| 43236 | Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance | Clinical Review by Code List PBCWA, Pg 337 Original policy |
| 43238 | Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound- guided intramural or transmural fine needle aspiration/biopsy(s) | Clinical Review by Code List PBCWA, Pg 337 Original policy |
| 43239 | Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple | Clinical Review by Code List PBCWA, Pg 337 Original policy |
| 43242 | Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound- guided intramural or transmural fine needle aspiration/biopsy(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 337 Original policy |
| 43257 | Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease | Clinical Review by Code List PBCWA, Pg 338 Original policy |
| 43280 | Laparoscopy, surgical, esophagogastric fundoplasty (e.g., Nissen, Toupet procedures) | Clinical Review by Code List PBCWA, Pg 338 Original policy |
| 43281 | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed, without implantation of mesh | Clinical Review by Code List PBCWA, Pg 338 Original policy |
| 43282 | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh | Clinical Review by Code List PBCWA, Pg 338 Original policy |
| 43644 | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux- en-Y gastroenterostomy | Clinical Review by Code List PBCWA, Pg 339 Original policy |