Premera Blue Cross of Washington prior authorization, page 22
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 |
|---|---|---|
| 77438 | Surface radiation therapy; orthovoltage, delivery, >150-500 KV, per fraction | Clinical Review by Code List PBCWA, Pg 424 Original policy |
| 77439 | Surface radiation therapy; superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for treatment of cutaneous utmors, per course of treatment (list separately in additiona to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 424 Original policy |
| 77469 | Intraoperative radiation treatment management | Clinical Review by Code List PBCWA, Pg 425 Original policy |
| 77470 | Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation) | Clinical Review by Code List PBCWA, Pg 425 Original policy |
| 77520 | Proton treatment delivery; simple, without compensation These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 425 Original policy |
| 77522 | Proton treatment delivery; simple, with compensation | Clinical Review by Code List PBCWA, Pg 426 Original policy |
| 77523 | Proton treatment delivery; intermediate | Clinical Review by Code List PBCWA, Pg 426 Original policy |
| 77525 | Proton treatment delivery; complex | Clinical Review by Code List PBCWA, Pg 426 Original policy |
| 77761 | Intracavitary radiation source application; simple These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 426 Original policy |
| 77762 | Intracavitary radiation source application; intermediate | Clinical Review by Code List PBCWA, Pg 427 Original policy |
| 77763 | Intracavitary radiation source application; complex | Clinical Review by Code List PBCWA, Pg 427 Original policy |
| 77767 | Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel | Clinical Review by Code List PBCWA, Pg 427 Original policy |
| 77768 | Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 427 Original policy |
| 77770 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel | Clinical Review by Code List PBCWA, Pg 428 Original policy |
| 77771 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels | Clinical Review by Code List PBCWA, Pg 428 Original policy |
| 77772 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels | Clinical Review by Code List PBCWA, Pg 428 Original policy |
| 77778 | Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 428 Original policy |
| 77790 | Supervision, handling, loading of radiation source | Clinical Review by Code List PBCWA, Pg 429 Original policy |
| 78429 | Myocardial imaging, positron emission tomography (pet), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan | Clinical Review by Code List PBCWA, Pg 430 Original policy |
| 78430 | Myocardial imaging, positron emission tomography (pet), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan | Clinical Review by Code List PBCWA, Pg 430 Original policy |
| 78431 | Myocardial imaging, positron emission tomography (pet), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan | Clinical Review by Code List PBCWA, Pg 430 Original policy |
| 78432 | Myocardial imaging, positron emission tomography (pet), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 430 Original policy |
| 78433 | Myocardial imaging, positron emission tomography (pet), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently acquired computed tomography transmission scan | Clinical Review by Code List PBCWA, Pg 431 Original policy |
| 78451 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress | Clinical Review by Code List PBCWA, Pg 431 Original policy |
| 78452 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress | Clinical Review by Code List PBCWA, Pg 431 Original policy |
| 78453 | Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 431 Original policy |
| 78454 | Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress | Clinical Review by Code List PBCWA, Pg 432 Original policy |
| 78459 | Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study | Clinical Review by Code List PBCWA, Pg 432 Original policy |
| 78466 | Myocardial imaging, infarct avid, planar; qualitative or quantitative | Clinical Review by Code List PBCWA, Pg 432 Original policy |
| 78468 | Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique | Clinical Review by Code List PBCWA, Pg 432 Original policy |
| 78469 | Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification | Clinical Review by Code List PBCWA, Pg 432 Original policy |
| 78472 | Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 432 Original policy |
| 78473 | Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification | Clinical Review by Code List PBCWA, Pg 433 Original policy |
| 78481 | Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification | Clinical Review by Code List PBCWA, Pg 433 Original policy |
| 78483 | Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/ or pharmacologic), wall motion study plus ejection fraction, with or without quantification | Clinical Review by Code List PBCWA, Pg 433 Original policy |
| 78491 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic) | Clinical Review by Code List PBCWA, Pg 433 Original policy |
| 78492 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 433 Original policy |
| 78494 | Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing | Clinical Review by Code List PBCWA, Pg 434 Original policy |
| 78608 | Brain imaging, positron emission tomography (PET); metabolic evaluation | Clinical Review by Code List PBCWA, Pg 434 Original policy |
| 78609 | Brain imaging, positron emission tomography (PET); perfusion evaluation | Clinical Review by Code List PBCWA, Pg 434 Original policy |
| 78811 | Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck) | Clinical Review by Code List PBCWA, Pg 435 Original policy |
| 78812 | Positron emission tomography (PET) imaging; skull base to mid-thigh | Clinical Review by Code List PBCWA, Pg 435 Original policy |
| 78813 | Positron emission tomography (PET) imaging; whole body | Clinical Review by Code List PBCWA, Pg 435 Original policy |
| 78814 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) | Clinical Review by Code List PBCWA, Pg 435 Original policy |
| 78815 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 435 Original policy |
| 78816 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body | Clinical Review by Code List PBCWA, Pg 436 Original policy |
| 79445 | Radiopharmaceutical therapy, by intra- arterial particulate administration | Clinical Review by Code List PBCWA, Pg 436 Original policy |
| 81120 | IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg, glioma), common variants (eg, R132H, R132C) | Clinical Review by Code List PBCWA, Pg 437 Original policy |
| 81121 | IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (eg, glioma), common variants (eg, R140W, R172M) | Clinical Review by Code List PBCWA, Pg 437 Original policy |
| 81161 | DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed | Clinical Review by Code List PBCWA, Pg 437 Original policy |