Premera Blue Cross of Washington prior authorization, page 19
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 |
|---|---|---|
| 69730 | Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside the mastoid and involving a bony defect greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex | Clinical Review by Code List PBCWA, Pg 388 Original policy |
| 69930 | Cochlear device implantation, with or without mastoidectomy | Clinical Review by Code List PBCWA, Pg 388 Original policy |
| 70336 | Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) | Clinical Review by Code List PBCWA, Pg 389 Original policy |
| 70450 | Computed tomography, head or brain; without contrast material | Clinical Review by Code List PBCWA, Pg 389 Original policy |
| 70460 | Computed tomography, head or brain; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 389 Original policy |
| 70470 | Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections | Clinical Review by Code List PBCWA, Pg 389 Original policy |
| 70471 | Computed tomographic angiography (CTA), head and neck, with contrast material(s), including noncontrast images, when performed, and image postprocessing These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 389 Original policy |
| 70472 | Computed tomographic (CT) cerebral perfusion analysis with contrast material(s), including image postprocessing performed with concurrent CT or CT angiography of the same anatomy (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 390 Original policy |
| 70473 | Computed tomographic (CT) cerebral perfusion analysis with contrast material(s), including image postprocessing performed without concurrent CT or CT angiography of the same anatomy | Clinical Review by Code List PBCWA, Pg 390 Original policy |
| 70480 | Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material | Clinical Review by Code List PBCWA, Pg 390 Original policy |
| 70481 | Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 390 Original policy |
| 70482 | Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 390 Original policy |
| 70486 | Computed tomography, maxillofacial area; without contrast material | Clinical Review by Code List PBCWA, Pg 391 Original policy |
| 70487 | Computed tomography, maxillofacial area; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 391 Original policy |
| 70488 | Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections | Clinical Review by Code List PBCWA, Pg 391 Original policy |
| 70490 | Computed tomography, soft tissue neck; without contrast material | Clinical Review by Code List PBCWA, Pg 391 Original policy |
| 70491 | Computed tomography, soft tissue neck; with contrast material(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 391 Original policy |
| 70492 | Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections | Clinical Review by Code List PBCWA, Pg 392 Original policy |
| 70496 | Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing | Clinical Review by Code List PBCWA, Pg 392 Original policy |
| 70498 | Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing | Clinical Review by Code List PBCWA, Pg 392 Original policy |
| 70540 | Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s) | Clinical Review by Code List PBCWA, Pg 392 Original policy |
| 70542 | Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 392 Original policy |
| 70543 | Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences | Clinical Review by Code List PBCWA, Pg 393 Original policy |
| 70544 | Magnetic resonance angiography, head; without contrast material(s) | Clinical Review by Code List PBCWA, Pg 393 Original policy |
| 70545 | MRA head; with contrast | Clinical Review by Code List PBCWA, Pg 393 Original policy |
| 70546 | Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences | Clinical Review by Code List PBCWA, Pg 393 Original policy |
| 70547 | Magnetic resonance angiography, neck; without contrast material(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 393 Original policy |
| 70548 | Magnetic resonance angiography, neck; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 394 Original policy |
| 70549 | Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences | Clinical Review by Code List PBCWA, Pg 394 Original policy |
| 70551 | Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material | Clinical Review by Code List PBCWA, Pg 394 Original policy |
| 70552 | Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) | Clinical Review by Code List PBCWA, Pg 394 Original policy |
| 70553 | Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 394 Original policy |
| 70554 | Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration | Clinical Review by Code List PBCWA, Pg 395 Original policy |
| 70555 | Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing | Clinical Review by Code List PBCWA, Pg 395 Original policy |
| 71250 | Computed tomography, thorax, diagnostic; without contrast material | Clinical Review by Code List PBCWA, Pg 395 Original policy |
| 71260 | Computed tomography, thorax, diagnostic; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 395 Original policy |
| 71270 | Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further sections These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 395 Original policy |
| 71271 | Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) | Clinical Review by Code List PBCWA, Pg 396 Original policy |
| 71275 | Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing | Clinical Review by Code List PBCWA, Pg 396 Original policy |
| 71550 | Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) | Clinical Review by Code List PBCWA, Pg 396 Original policy |
| 71551 | Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s) | Clinical Review by Code List PBCWA, Pg 396 Original policy |
| 71552 | Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 396 Original policy |
| 71555 | MRA chest; with or w/o contrast | Clinical Review by Code List PBCWA, Pg 397 Original policy |
| 72125 | Computed tomography, cervical spine; without contrast material | Clinical Review by Code List PBCWA, Pg 397 Original policy |
| 72126 | Computed tomography, cervical spine; with contrast material | Clinical Review by Code List PBCWA, Pg 397 Original policy |
| 72127 | Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections | Clinical Review by Code List PBCWA, Pg 397 Original policy |
| 72128 | Computed tomography, thoracic spine; without contrast material These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 397 Original policy |
| 72129 | Computed tomography, thoracic spine; with contrast material | Clinical Review by Code List PBCWA, Pg 398 Original policy |
| 72130 | Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections | Clinical Review by Code List PBCWA, Pg 398 Original policy |
| 72131 | Computed tomography, lumbar spine; without contrast material | Clinical Review by Code List PBCWA, Pg 398 Original policy |