Premera Blue Cross of Washington prior authorization, page 16
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 |
|---|---|---|
| 55860 | Exposure of prostate, any approach, for insertion of radioactive substance | Clinical Review by Code List PBCWA, Pg 353 Original policy |
| 55862 | Exposure of prostate, any approach, for insertion of radioactive substance; with lymph node biopsy(s) (limited pelvic lymphadenectomy) | Clinical Review by Code List PBCWA, Pg 353 Original policy |
| 55865 | Exposure of prostate, any approach, for insertion of radioactive substance; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes | Clinical Review by Code List PBCWA, Pg 353 Original policy |
| 55874 | Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 353 Original policy |
| 55875 | Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy | Clinical Review by Code List PBCWA, Pg 354 Original policy |
| 55920 | Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application | Clinical Review by Code List PBCWA, Pg 355 Original policy |
| 55970 | Intersex surgery; male to female | Clinical Review by Code List PBCWA, Pg 355 Original policy |
| 55980 | Intersex surgery; female to male | Clinical Review by Code List PBCWA, Pg 355 Original policy |
| 56625 | Vulvectomy simple; complete | Clinical Review by Code List PBCWA, Pg 355 Original policy |
| 56805 | Clitoroplasty for intersex state These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 355 Original policy |
| 57110 | Vaginectomy, complete removal of vaginal wall | Clinical Review by Code List PBCWA, Pg 356 Original policy |
| 57155 | Insertion of uterine tandems and/or vaginal ovoid for clinical brachytherapy | Clinical Review by Code List PBCWA, Pg 356 Original policy |
| 57156 | Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy | Clinical Review by Code List PBCWA, Pg 356 Original policy |
| 57291 | Construction of artificial vagina; without graft | Clinical Review by Code List PBCWA, Pg 356 Original policy |
| 57292 | Construction of artificial vagina; with graft | Clinical Review by Code List PBCWA, Pg 356 Original policy |
| 57335 | Vaginoplasty for intersex state These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 356 Original policy |
| 58150 | Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) | Clinical Review by Code List PBCWA, Pg 357 Original policy |
| 58152 | Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (eg, Marshall- Marchetti-Krantz, Burch) | Clinical Review by Code List PBCWA, Pg 357 Original policy |
| 58180 | Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) | Clinical Review by Code List PBCWA, Pg 357 Original policy |
| 58260 | Vaginal hysterectomy, for uterus 250 g or less | Clinical Review by Code List PBCWA, Pg 357 Original policy |
| 58262 | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s) | Clinical Review by Code List PBCWA, Pg 357 Original policy |
| 58263 | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 357 Original policy |
| 58267 | Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall- Marchetti-Krantz type, Pereyra type) with or without endoscopic control | Clinical Review by Code List PBCWA, Pg 358 Original policy |
| 58270 | Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele | Clinical Review by Code List PBCWA, Pg 358 Original policy |
| 58275 | Vaginal hysterectomy, with total or partial vaginectomy | Clinical Review by Code List PBCWA, Pg 358 Original policy |
| 58280 | Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele | Clinical Review by Code List PBCWA, Pg 358 Original policy |
| 58290 | Vaginal hysterectomy, for uterus greater than 250 grams | Clinical Review by Code List PBCWA, Pg 358 Original policy |
| 58291 | Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 358 Original policy |
| 58292 | Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele | Clinical Review by Code List PBCWA, Pg 359 Original policy |
| 58294 | Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele | Clinical Review by Code List PBCWA, Pg 359 Original policy |
| 58346 | Insertion of Heyman capsules for clinical brachytherapy | Clinical Review by Code List PBCWA, Pg 359 Original policy |
| 58541 | Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less | Clinical Review by Code List PBCWA, Pg 359 Original policy |
| 58542 | Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) | Clinical Review by Code List PBCWA, Pg 359 Original policy |
| 58543 | Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g | Clinical Review by Code List PBCWA, Pg 359 Original policy |
| 58544 | Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 359 Original policy |
| 58550 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less | Clinical Review by Code List PBCWA, Pg 360 Original policy |
| 58552 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) | Clinical Review by Code List PBCWA, Pg 360 Original policy |
| 58553 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams | Clinical Review by Code List PBCWA, Pg 360 Original policy |
| 58554 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) | Clinical Review by Code List PBCWA, Pg 360 Original policy |
| 58570 | Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less | Clinical Review by Code List PBCWA, Pg 360 Original policy |
| 58571 | Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) | Clinical Review by Code List PBCWA, Pg 360 Original policy |
| 58572 | Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g | Clinical Review by Code List PBCWA, Pg 360 Original policy |
| 58573 | Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 360 Original policy |
| 58672 | Laparoscopy, surgical; with fimbrioplasty | Clinical Review by Code List PBCWA, Pg 361 Original policy |
| 58673 | Laparoscopy, surgical; with salpingostomy (salpingoneostomy) | Clinical Review by Code List PBCWA, Pg 361 Original policy |
| 58750 | Tubotubal anastomosis | Clinical Review by Code List PBCWA, Pg 361 Original policy |
| 58760 | Fimbrioplasty | Clinical Review by Code List PBCWA, Pg 361 Original policy |
| 60660 | Ablation of 1 or more thyroid nodule(s), one lobe or the isthmus, percutaneous, including imaging guidance, radiofrequency | Clinical Review by Code List PBCWA, Pg 362 Original policy |
| 60661 | Ablation of 1 or more thyroid nodule(s), additional lobe, percutaneous, including imaging guidance, radiofrequency (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 362 Original policy |
| 61796 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion | Clinical Review by Code List PBCWA, Pg 363 Original policy |