Premera Blue Cross of Washington prior authorization, page 15
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 |
|---|---|---|
| 43645 | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass small intestine reconstruction to limit absorption | Clinical Review by Code List PBCWA, Pg 339 Original policy |
| 43647 | Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum | Clinical Review by Code List PBCWA, Pg 339 Original policy |
| 43648 | Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum | Clinical Review by Code List PBCWA, Pg 339 Original policy |
| 43770 | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components | Clinical Review by Code List PBCWA, Pg 340 Original policy |
| 43771 | Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric band component only | Clinical Review by Code List PBCWA, Pg 340 Original policy |
| 43772 | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band component only | Clinical Review by Code List PBCWA, Pg 340 Original policy |
| 43773 | Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric band component only | Clinical Review by Code List PBCWA, Pg 340 Original policy |
| 43774 | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band and subcutaneous port components | Clinical Review by Code List PBCWA, Pg 340 Original policy |
| 43775 | Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) | Clinical Review by Code List PBCWA, Pg 340 Original policy |
| 43842 | Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical- banded gastroplasty | Clinical Review by Code List PBCWA, Pg 340 Original policy |
| 43843 | Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty | Clinical Review by Code List PBCWA, Pg 340 Original policy |
| 43845 | Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 340 Original policy |
| 43846 | Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy | Clinical Review by Code List PBCWA, Pg 341 Original policy |
| 43847 | Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption | Clinical Review by Code List PBCWA, Pg 341 Original policy |
| 43848 | Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) | Clinical Review by Code List PBCWA, Pg 341 Original policy |
| 43881 | Implantation or replacement of gastric neurostimulator electrodes, antrum, open | Clinical Review by Code List PBCWA, Pg 341 Original policy |
| 43882 | Revision or removal of gastric neurostimulator electrodes, antrum, open | Clinical Review by Code List PBCWA, Pg 341 Original policy |
| 43886 | Gastric restrictive procedure, open; revision of subcutaneous port component only | Clinical Review by Code List PBCWA, Pg 341 Original policy |
| 43887 | Gastric restrictive procedure, open; removal of subcutaneous port component only | Clinical Review by Code List PBCWA, Pg 341 Original policy |
| 43888 | Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 341 Original policy |
| 44135 | Intestinal allotransplantation; from cadaver donor | Clinical Review by Code List PBCWA, Pg 342 Original policy |
| 44136 | Intestinal allotransplantation; from living donor | Clinical Review by Code List PBCWA, Pg 342 Original policy |
| 46505 | Chemodenervation of internal anal sphincter | Clinical Review by Code List PBCWA, Pg 343 Original policy |
| 47135 | Liver allotransplantation; orthoptic; partial or whole, from cadaver or These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 343 Original policy |
| 47382 | Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency | Clinical Review by Code List PBCWA, Pg 344 Original policy |
| 48160 | Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells | Clinical Review by Code List PBCWA, Pg 344 Original policy |
| 48554 | Transplantation of pancreatic allograft These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 344 Original policy |
| 49591 | Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible | Clinical Review by Code List PBCWA, Pg 345 Original policy |
| 49593 | Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, reducible | Clinical Review by Code List PBCWA, Pg 345 Original policy |
| 49595 | Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, reducible These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 345 Original policy |
| 49613 | Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible | Clinical Review by Code List PBCWA, Pg 346 Original policy |
| 49615 | Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, reducible | Clinical Review by Code List PBCWA, Pg 346 Original policy |
| 49617 | Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, reducible | Clinical Review by Code List PBCWA, Pg 346 Original policy |
| 50250 | Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed | Clinical Review by Code List PBCWA, Pg 347 Original policy |
| 50360 | Renal allotransplantation; implantation of graft; without recipient | Clinical Review by Code List PBCWA, Pg 347 Original policy |
| 50365 | Renal allotransplantation, implantation of graft; with recipient nephrectomy | Clinical Review by Code List PBCWA, Pg 347 Original policy |
| 50542 | Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when performed | Clinical Review by Code List PBCWA, Pg 347 Original policy |
| 50592 | Ablation, one or more renal tumor(s), percutaneous, unilateral, radiofrequency | Clinical Review by Code List PBCWA, Pg 347 Original policy |
| 50593 | Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy | Clinical Review by Code List PBCWA, Pg 347 Original policy |
| 52287 | Cystourethroscopy, with injection(s) for chemodenervation of the bladder | Clinical Review by Code List PBCWA, Pg 348 Original policy |
| 52441 | Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant | Clinical Review by Code List PBCWA, Pg 348 Original policy |
| 52442 | Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant | Clinical Review by Code List PBCWA, Pg 348 Original policy |
| 52597 | Transurethral robotic-assisted waterjet resection of prostate, including intraoperative planning, ultrasound guidance, control of postoperative bleeding, complete, including vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy, when performed | Clinical Review by Code List PBCWA, Pg 349 Original policy |
| 53430 | Urethroplasty, reconstruction of female urethra | Clinical Review by Code List PBCWA, Pg 349 Original policy |
| 53854 | Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy | Clinical Review by Code List PBCWA, Pg 349 Original policy |
| 54125 | Amputation of penis; complete | Clinical Review by Code List PBCWA, Pg 350 Original policy |
| 54520 | Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach | Clinical Review by Code List PBCWA, Pg 352 Original policy |
| 54660 | Insertion of testicular prosthesis (separate procedure) | Clinical Review by Code List PBCWA, Pg 352 Original policy |
| 55180 | Scrotoplasty; complicated | Clinical Review by Code List PBCWA, Pg 352 Original policy |
| 55400 | Vasovasostomy, vasovasorrhaphy | Clinical Review by Code List PBCWA, Pg 352 Original policy |