Premera Blue Cross of Washington prior authorization, page 17
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 |
|---|---|---|
| 61800 | Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 363 Original policy |
| 61850 | Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical | Clinical Review by Code List PBCWA, Pg 364 Original policy |
| 61860 | Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical | Clinical Review by Code List PBCWA, Pg 364 Original policy |
| 61863 | Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site without use of intraoperative microelectrode recording; first array | Clinical Review by Code List PBCWA, Pg 364 Original policy |
| 61864 | Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site without use of intraoperative microelectrode recording; each additional array | Clinical Review by Code List PBCWA, Pg 364 Original policy |
| 61867 | Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site with use of intraoperative microelectrode recording; first array | Clinical Review by Code List PBCWA, Pg 364 Original policy |
| 61868 | Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site with use of intraoperative microelectrode recording; each additional array These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 364 Original policy |
| 61885 | Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array | Clinical Review by Code List PBCWA, Pg 365 Original policy |
| 61886 | Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays | Clinical Review by Code List PBCWA, Pg 365 Original policy |
| 61889 | Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, when performed, with direct or inductive coupling with connection | Clinical Review by Code List PBCWA, Pg 365 Original policy |
| 61891 | Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode array(s) | Clinical Review by Code List PBCWA, Pg 365 Original policy |
| 62281 | Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic | Clinical Review by Code List PBCWA, Pg 365 Original policy |
| 63001 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 366 Original policy |
| 63005 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy, 1 or 2 vertebral segments; lumbar, except for spondylolisthesis | Clinical Review by Code List PBCWA, Pg 367 Original policy |
| 63012 | Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) | Clinical Review by Code List PBCWA, Pg 367 Original policy |
| 63015 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 367 Original policy |
| 63017 | Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar | Clinical Review by Code List PBCWA, Pg 368 Original policy |
| 63020 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical | Clinical Review by Code List PBCWA, Pg 368 Original policy |
| 63030 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 368 Original policy |
| 63032 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and excision of herniated intervertebral disc; with repair of annular defect by implantation of bone-anchored annular closure device, including all imaging guidance, 1 interspace, lumbar (list separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 369 Original policy |
| 63035 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar | Clinical Review by Code List PBCWA, Pg 369 Original policy |
| 63040 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical | Clinical Review by Code List PBCWA, Pg 369 Original policy |
| 63042 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 369 Original policy |
| 63044 | Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace | Clinical Review by Code List PBCWA, Pg 370 Original policy |
| 63045 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 370 Original policy |
| 63047 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar | Clinical Review by Code List PBCWA, Pg 371 Original policy |
| 63048 | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar | Clinical Review by Code List PBCWA, Pg 371 Original policy |
| 63050 | Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments | Clinical Review by Code List PBCWA, Pg 371 Original policy |
| 63051 | Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non- segmental fixation devices [eg, wire, suture, mini-plates], when performed) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 371 Original policy |
| 63052 | Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 372 Original policy |
| 63053 | Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional segment (List separately in addition to code for primary procedure)T | Clinical Review by Code List PBCWA, Pg 372 Original policy |
| 63056 | Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 372 Original policy |
| 63057 | Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 373 Original policy |
| 63075 | Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace | Clinical Review by Code List PBCWA, Pg 373 Original policy |
| 63081 | Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 373 Original policy |
| 63185 | Laminectomy with rhizotomy; 1 or 2 segments | Clinical Review by Code List PBCWA, Pg 374 Original policy |
| 63190 | Laminectomy with rhizotomy; more than 2 segments | Clinical Review by Code List PBCWA, Pg 374 Original policy |
| 63191 | Laminectomy with section of spinal accessory nerve These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 374 Original policy |
| 63265 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical | Clinical Review by Code List PBCWA, Pg 375 Original policy |
| 63267 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar | Clinical Review by Code List PBCWA, Pg 375 Original policy |
| 63272 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar | Clinical Review by Code List PBCWA, Pg 375 Original policy |
| 63620 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 375 Original policy |
| 63621 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 376 Original policy |
| 63650 | Percutaneous implantation of neurostimulator electrode array, epidural | Clinical Review by Code List PBCWA, Pg 376 Original policy |
| 63655 | Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural | Clinical Review by Code List PBCWA, Pg 376 Original policy |
| 63661 | Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed | Clinical Review by Code List PBCWA, Pg 376 Original policy |
| 63662 | Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 376 Original policy |
| 63663 | Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed | Clinical Review by Code List PBCWA, Pg 377 Original policy |
| 63664 | Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed | Clinical Review by Code List PBCWA, Pg 377 Original policy |
| 63685 | Insertion or replacement of spinal neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator receiver | Clinical Review by Code List PBCWA, Pg 377 Original policy |