Premera Blue Cross of Washington prior authorization, page 21
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 |
|---|---|---|
| 74181 | Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) | Clinical Review by Code List PBCWA, Pg 408 Original policy |
| 74182 | Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 408 Original policy |
| 74183 | Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences | Clinical Review by Code List PBCWA, Pg 409 Original policy |
| 74185 | Magnetic resonance angiography, abdomen, with or without contrast material(s) | Clinical Review by Code List PBCWA, Pg 409 Original policy |
| 74261 | Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material | Clinical Review by Code List PBCWA, Pg 409 Original policy |
| 74262 | Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non- contrast images, if performed | Clinical Review by Code List PBCWA, Pg 409 Original policy |
| 74263 | Computed tomographic (CT) colonography, screening, including image postprocessing These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 409 Original policy |
| 74712 | Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation | Clinical Review by Code List PBCWA, Pg 410 Original policy |
| 75557 | Cardiac magnetic resonance imaging for morphology and function without contrast material | Clinical Review by Code List PBCWA, Pg 410 Original policy |
| 75559 | Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging | Clinical Review by Code List PBCWA, Pg 410 Original policy |
| 75561 | Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences | Clinical Review by Code List PBCWA, Pg 410 Original policy |
| 75563 | Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging | Clinical Review by Code List PBCWA, Pg 410 Original policy |
| 75565 | Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 410 Original policy |
| 75571 | Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium | Clinical Review by Code List PBCWA, Pg 411 Original policy |
| 75572 | Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) | Clinical Review by Code List PBCWA, Pg 411 Original policy |
| 75573 | Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function) | Clinical Review by Code List PBCWA, Pg 411 Original policy |
| 75574 | Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 411 Original policy |
| 75580 | Noninvasive estimate of coronary fractional flow reserve derived from augmentative software analysis of the data set from a coronary computed tomography angiography | Clinical Review by Code List PBCWA, Pg 412 Original policy |
| 75635 | Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, performed, and image postprocessing | Clinical Review by Code List PBCWA, Pg 412 Original policy |
| 75894 | Transcatheter therapy, embolization, any method, radiological supervision and interpretation These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 412 Original policy |
| 76390 | Magnetic resonance spectroscopy | Clinical Review by Code List PBCWA, Pg 416 Original policy |
| 76391 | Magnetic resonance (eg, vibration) elastography | Clinical Review by Code List PBCWA, Pg 416 Original policy |
| 76873 | Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure) | Clinical Review by Code List PBCWA, Pg 417 Original policy |
| 76965 | Ultrasonic guidance for interstitial radioelement application | Clinical Review by Code List PBCWA, Pg 417 Original policy |
| 77046 | Magnetic resonance imaging, breast, without contrast material; unilateral | Clinical Review by Code List PBCWA, Pg 417 Original policy |
| 77047 | Magnetic resonance imaging, breast, without contrast material; bilateral These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 417 Original policy |
| 77048 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (cad real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral | Clinical Review by Code List PBCWA, Pg 418 Original policy |
| 77049 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (cad real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral | Clinical Review by Code List PBCWA, Pg 418 Original policy |
| 77078 | Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) | Clinical Review by Code List PBCWA, Pg 418 Original policy |
| 77084 | Magnetic resonance (eg, proton) imaging, bone marrow blood supply These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 418 Original policy |
| 77295 | 3-dimensional radiotherapy plan, including dose-volume histograms | Clinical Review by Code List PBCWA, Pg 419 Original policy |
| 77301 | Intensity modulated radiotherapy plan including dose-volume histograms for target and critical structure partial tolerance specifications | Clinical Review by Code List PBCWA, Pg 419 Original policy |
| 77316 | Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 419 Original policy |
| 77317 | Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s) | Clinical Review by Code List PBCWA, Pg 420 Original policy |
| 77318 | Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) | Clinical Review by Code List PBCWA, Pg 420 Original policy |
| 77338 | Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan | Clinical Review by Code List PBCWA, Pg 420 Original policy |
| 77370 | Special medical radiation physics consultation These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 420 Original policy |
| 77371 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cerebral lesion(s) consisting of 1 session; multisource Cobalt 60 based or more lesions, including image guidance, entire course not to exceed 5 fractions | Clinical Review by Code List PBCWA, Pg 421 Original policy |
| 77372 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of session; linear accelerator based | Clinical Review by Code List PBCWA, Pg 421 Original policy |
| 77373 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions | Clinical Review by Code List PBCWA, Pg 421 Original policy |
| 77387 | Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 421 Original policy |
| 77402 | Radiation treatment delivery,=>1 MeV; simple | Clinical Review by Code List PBCWA, Pg 422 Original policy |
| 77407 | Radiation treatment delivery, =>1 MeV; intermediate These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 422 Original policy |
| 77412 | Radiation treatment delivery, =>1 MeV; complex | Clinical Review by Code List PBCWA, Pg 423 Original policy |
| 77424 | Intraoperative radiation treatment delivery, x-ray, single treatment session | Clinical Review by Code List PBCWA, Pg 423 Original policy |
| 77425 | Intraoperative radiation treatment delivery, electrons, single treatment session | Clinical Review by Code List PBCWA, Pg 423 Original policy |
| 77432 | Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 423 Original policy |
| 77435 | Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions | Clinical Review by Code List PBCWA, Pg 424 Original policy |
| 77436 | Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field stetting | Clinical Review by Code List PBCWA, Pg 424 Original policy |
| 77437 | Surface radiation therapy; superficial, delivery, =150 KV, per fraction (e.g., electronic brachyterhapy) | Clinical Review by Code List PBCWA, Pg 424 Original policy |