Premera Blue Cross of Washington prior authorization, page 18
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 |
|---|---|---|
| 63688 | Revision or removal of implanted spinal neurostimulator pulse generator or receiver, with detachable connection to electrode array | Clinical Review by Code List PBCWA, Pg 377 Original policy |
| 64553 | Percutaneous implantation of neurostimulator electrodes; cranial nerve | Clinical Review by Code List PBCWA, Pg 377 Original policy |
| 64561 | Percutaneous implantation of neurostimulator electrodes sacral nerve (transforaminal placement) | Clinical Review by Code List PBCWA, Pg 378 Original policy |
| 64568 | Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator | Clinical Review by Code List PBCWA, Pg 378 Original policy |
| 64569 | Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator | Clinical Review by Code List PBCWA, Pg 378 Original policy |
| 64581 | Incision of implantation of neurostimulator electrodes sacral nerve (transforaminal placement) | Clinical Review by Code List PBCWA, Pg 378 Original policy |
| 64582 | Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array | Clinical Review by Code List PBCWA, Pg 378 Original policy |
| 64583 | Revision or replacement of hypoglossal nerve neurostimulator array and distal respiratory sensor electrode or electrode array, including connection to existing pulse generator | Clinical Review by Code List PBCWA, Pg 378 Original policy |
| 64584 | Removal of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 378 Original policy |
| 64600 | Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch | Clinical Review by Code List PBCWA, Pg 379 Original policy |
| 64611 | Chemodenervation of parotid and submandibular salivary glands, bilateral These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 379 Original policy |
| 64612 | Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm) | Clinical Review by Code List PBCWA, Pg 380 Original policy |
| 64615 | Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine) | Clinical Review by Code List PBCWA, Pg 380 Original policy |
| 64616 | Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis) | Clinical Review by Code List PBCWA, Pg 380 Original policy |
| 64617 | Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle electromyography, when performed | Clinical Review by Code List PBCWA, Pg 380 Original policy |
| 64633 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint | Clinical Review by Code List PBCWA, Pg 381 Original policy |
| 64634 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 381 Original policy |
| 64635 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint | Clinical Review by Code List PBCWA, Pg 381 Original policy |
| 64636 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 381 Original policy |
| 64640 | Destruction by neurolytic agent; other peripheral nerve or branch These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 381 Original policy |
| 64642 | Chemodenervation of one extremity; 1-4 muscle(s) | Clinical Review by Code List PBCWA, Pg 382 Original policy |
| 64643 | Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 382 Original policy |
| 64644 | Chemodenervation of one extremity; 5 or more muscles | Clinical Review by Code List PBCWA, Pg 382 Original policy |
| 64645 | Chemodenervation of one extremity; each additional extremity, 5 or more muscles (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 382 Original policy |
| 64646 | Chemodenervation of trunk muscle(s); 1-5 muscle(s) | Clinical Review by Code List PBCWA, Pg 382 Original policy |
| 64647 | Chemodenervation of trunk muscle(s); 6 or more muscles | Clinical Review by Code List PBCWA, Pg 382 Original policy |
| 64650 | Chemodenervation of eccrine glands; both axillae | Clinical Review by Code List PBCWA, Pg 382 Original policy |
| 64653 | Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 382 Original policy |
| 64721 | Neuroplasty and/or transposition; median nerve at carpal tunnel | Clinical Review by Code List PBCWA, Pg 383 Original policy |
| 64818 | Sympathectomy, lumbar | Clinical Review by Code List PBCWA, Pg 383 Original policy |
| 67218 | Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; radiation by implantation of source (includes removal of source) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 383 Original policy |
| 67345 | Chemodenervation of extraocular muscle | Clinical Review by Code List PBCWA, Pg 384 Original policy |
| 67900 | Repair of brow ptosis (supraciliary, mid- forehead or coronal approach) | Clinical Review by Code List PBCWA, Pg 384 Original policy |
| 67901 | Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) | Clinical Review by Code List PBCWA, Pg 384 Original policy |
| 67902 | Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 384 Original policy |
| 67903 | Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach | Clinical Review by Code List PBCWA, Pg 385 Original policy |
| 67904 | Repair of blepharoptosis; (tarso) levator resection or advancement, external approach | Clinical Review by Code List PBCWA, Pg 385 Original policy |
| 67906 | Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) | Clinical Review by Code List PBCWA, Pg 385 Original policy |
| 67908 | Repair of blepharoptosis; conjunctivo-tarso- Muller's muscle-levator resection (eg, Fasanella-Servat type) | Clinical Review by Code List PBCWA, Pg 385 Original policy |
| 67950 | Canthoplasty (reconstruction of canthus) | Clinical Review by Code List PBCWA, Pg 385 Original policy |
| 69676 | Tympanic neurectomy | Clinical Review by Code List PBCWA, Pg 386 Original policy |
| 69705 | Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); unilateral | Clinical Review by Code List PBCWA, Pg 386 Original policy |
| 69706 | Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); bilateral | Clinical Review by Code List PBCWA, Pg 386 Original policy |
| 69710 | Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone | Clinical Review by Code List PBCWA, Pg 386 Original policy |
| 69711 | Removal or repair of electromagnetic bone conduction hearing device in temporal bone These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 386 Original policy |
| 69714 | Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy | Clinical Review by Code List PBCWA, Pg 387 Original policy |
| 69716 | Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or resulting in removal of less than 100 sq mm surface area of bone deep to the outer cranial cortex | Clinical Review by Code List PBCWA, Pg 387 Original policy |
| 69717 | Replacement (including removal of existing device), osseointegrated implant, skull; with percutaneous attachment to external speech processor | Clinical Review by Code List PBCWA, Pg 387 Original policy |
| 69719 | Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or involving a bony defect less than 100 sq mm surface area of bone deep to the outer cranial cortex | Clinical Review by Code List PBCWA, Pg 387 Original policy |
| 69729 | Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside of the mastoid and resulting in removal of greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 387 Original policy |