Premera Blue Cross of Washington prior authorization, page 20
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 |
|---|---|---|
| 72132 | Computed tomography, lumbar spine; with contrast material | Clinical Review by Code List PBCWA, Pg 398 Original policy |
| 72133 | Computed tomography, lumbar spine; 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 398 Original policy |
| 72141 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material | Clinical Review by Code List PBCWA, Pg 399 Original policy |
| 72142 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 399 Original policy |
| 72146 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material | Clinical Review by Code List PBCWA, Pg 399 Original policy |
| 72147 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 399 Original policy |
| 72148 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 399 Original policy |
| 72149 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 400 Original policy |
| 72156 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical | Clinical Review by Code List PBCWA, Pg 400 Original policy |
| 72157 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic | Clinical Review by Code List PBCWA, Pg 400 Original policy |
| 72158 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar | Clinical Review by Code List PBCWA, Pg 400 Original policy |
| 72159 | Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 400 Original policy |
| 72191 | Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing | Clinical Review by Code List PBCWA, Pg 401 Original policy |
| 72192 | Computed tomography, pelvis; without contrast material | Clinical Review by Code List PBCWA, Pg 401 Original policy |
| 72193 | Computed tomography, pelvis; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 401 Original policy |
| 72194 | Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections | Clinical Review by Code List PBCWA, Pg 401 Original policy |
| 72195 | Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 401 Original policy |
| 72196 | Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 402 Original policy |
| 72197 | Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences | Clinical Review by Code List PBCWA, Pg 402 Original policy |
| 72198 | Magnetic resonance angiography, pelvis, with or without contrast material(s) | Clinical Review by Code List PBCWA, Pg 402 Original policy |
| 73200 | Computed tomography, upper extremity; without contrast material | Clinical Review by Code List PBCWA, Pg 402 Original policy |
| 73201 | Computed tomography, upper extremity; with contrast material(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 402 Original policy |
| 73202 | Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections | Clinical Review by Code List PBCWA, Pg 403 Original policy |
| 73206 | Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing | Clinical Review by Code List PBCWA, Pg 403 Original policy |
| 73218 | Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s) | Clinical Review by Code List PBCWA, Pg 403 Original policy |
| 73219 | Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 403 Original policy |
| 73220 | Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; 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 403 Original policy |
| 73221 | Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) | Clinical Review by Code List PBCWA, Pg 404 Original policy |
| 73222 | Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 404 Original policy |
| 73223 | Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences | Clinical Review by Code List PBCWA, Pg 404 Original policy |
| 73225 | Magnetic resonance angiography, upper extremity, with or without contrast material(s) | Clinical Review by Code List PBCWA, Pg 404 Original policy |
| 73700 | Computed tomography, lower extremity; without contrast material These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 404 Original policy |
| 73701 | Computed tomography, lower extremity; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 405 Original policy |
| 73702 | Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections | Clinical Review by Code List PBCWA, Pg 405 Original policy |
| 73706 | Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing | Clinical Review by Code List PBCWA, Pg 405 Original policy |
| 73718 | Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) | Clinical Review by Code List PBCWA, Pg 405 Original policy |
| 73719 | Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 405 Original policy |
| 73720 | Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences | Clinical Review by Code List PBCWA, Pg 406 Original policy |
| 73721 | Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material | Clinical Review by Code List PBCWA, Pg 406 Original policy |
| 73722 | Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 406 Original policy |
| 73723 | Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences | Clinical Review by Code List PBCWA, Pg 406 Original policy |
| 73725 | Magnetic resonance angiography, lower extremity, with or without contrast material(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 406 Original policy |
| 74150 | Computed tomography, abdomen; without contrast material | Clinical Review by Code List PBCWA, Pg 407 Original policy |
| 74160 | Computed tomography, abdomen; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 407 Original policy |
| 74170 | Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections | Clinical Review by Code List PBCWA, Pg 407 Original policy |
| 74174 | Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, performed, and image postprocessing | Clinical Review by Code List PBCWA, Pg 407 Original policy |
| 74175 | Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 407 Original policy |
| 74176 | Computed tomography, abdomen and pelvis; without contrast material | Clinical Review by Code List PBCWA, Pg 408 Original policy |
| 74177 | Computed tomography, abdomen and pelvis; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 408 Original policy |
| 74178 | Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions | Clinical Review by Code List PBCWA, Pg 408 Original policy |