Premera Blue Cross of Washington prior authorization, page 28
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 |
|---|---|---|
| 81595 | Cardiology (heart transplant), mRNA, gene expression profiling by real-time quantitative PCR of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score | Clinical Review by Code List PBCWA, Pg 500 Original policy |
| 81599 | Unlisted multianalyte assay with algorithmic analysis | Clinical Review by Code List PBCWA, Pg 500 Original policy |
| 90283 | Immune globulin (IgIV), human, for intravenous use | Clinical Review by Code List PBCWA, Pg 505 Original policy |
| 90284 | Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each | Clinical Review by Code List PBCWA, Pg 505 Original policy |
| 90291 | Cytomegalovirus immune globulin (CMV- IgIV), human, for intravenous use These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 505 Original policy |
| 90867 | Therapeutic repetitive transcranial magnetic stimulation treatment; planning | Clinical Review by Code List PBCWA, Pg 506 Original policy |
| 90868 | Therapeutic repetitive transcranial magnetic stimulation treatment; delivery and management, per session | Clinical Review by Code List PBCWA, Pg 506 Original policy |
| 90869 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re- determination with delivery and management | Clinical Review by Code List PBCWA, Pg 506 Original policy |
| 92640 | Diagnostic analysis with programming of auditory brainstem implant, per hour | Clinical Review by Code List PBCWA, Pg 508 Original policy |
| 92920 | Percutaneous transluminal coronary angioplasty; single major coronary artery or branch | Clinical Review by Code List PBCWA, Pg 508 Original policy |
| 92924 | Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery and/or its branch(es) | Clinical Review by Code List PBCWA, Pg 508 Original policy |
| 92928 | Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery and/or its branch(es); 1 lesion involving 1 or more coronary segments These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 508 Original policy |
| 92930 | Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed, single major coronary artery and/or its branch(es); 2 or more distinct coronary lesions with 2 or more coronary stents deployed in 2 or more coronary segments, or a bifurcation lesion requiring angioplasty and/or stenting in both the main artery and the side branch | Clinical Review by Code List PBCWA, Pg 509 Original policy |
| 92933 | Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery and/or its branch(es) | Clinical Review by Code List PBCWA, Pg 509 Original policy |
| 92937 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed, single major coronary artery and/or its branch(es) | Clinical Review by Code List PBCWA, Pg 509 Original policy |
| 92943 | Percutaneous transluminal revascularization of chronic total occlusion, single coronary artery, coronary artery branch, or coronary artery bypass graft, and/or subtended major coronary artery banches of the bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; angegrade approach These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 509 Original policy |
| 92945 | Percutaneous transluminal revascularization of chronic total occlusion, single coronary artery, coronary artery branch, or coronary artery bypass graft, and/or subtended major coronary artery branches of the bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; combined antegrade and retrograde approaches | Clinical Review by Code List PBCWA, Pg 510 Original policy |
| 93228 | External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 510 Original policy |
| 93229 | External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports | Clinical Review by Code List PBCWA, Pg 511 Original policy |
| 93261 | Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system | Clinical Review by Code List PBCWA, Pg 511 Original policy |
| 93287 | Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review and report by a physician or other qualified health care professional; single, dual, or multiple lead implantable defibrillator system | Clinical Review by Code List PBCWA, Pg 512 Original policy |
| 93303 | Transthoracic echocardiography for congenital cardiac anomalies; complete | Clinical Review by Code List PBCWA, Pg 512 Original policy |
| 93304 | Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study | Clinical Review by Code List PBCWA, Pg 512 Original policy |
| 93306 | Echocardiography, transthoracic, real-time with image documentation (2D), includes M- mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 512 Original policy |
| 93307 | Echocardiography, transthoracic, real-time with image documentation (2D), includes M- mode recording, when performed, complete, without spectral or color Doppler echocardiography | Clinical Review by Code List PBCWA, Pg 513 Original policy |
| 93308 | Echocardiography, transthoracic, real-time with image documentation (2D), includes M- mode recording, when performed, follow-up or limited study | Clinical Review by Code List PBCWA, Pg 513 Original policy |
| 93312 | Echocardiography, transesophageal, real- time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report | Clinical Review by Code List PBCWA, Pg 513 Original policy |
| 93313 | Echocardiography, transesophageal, real- time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only | Clinical Review by Code List PBCWA, Pg 513 Original policy |
| 93314 | Echocardiography, transesophageal, real- time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only | Clinical Review by Code List PBCWA, Pg 513 Original policy |
| 93315 | Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 513 Original policy |
| 93316 | Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only | Clinical Review by Code List PBCWA, Pg 514 Original policy |
| 93317 | Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only | Clinical Review by Code List PBCWA, Pg 514 Original policy |
| 93350 | Echocardiography, transthoracic, real-time with image documentation (2D), includes M- mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report | Clinical Review by Code List PBCWA, Pg 514 Original policy |
| 93351 | Echocardiography, transthoracic, real-time with image documentation (2D), includes M- mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 514 Original policy |
| 93454 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation | Clinical Review by Code List PBCWA, Pg 515 Original policy |
| 93455 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation | Clinical Review by Code List PBCWA, Pg 515 Original policy |
| 93456 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization | Clinical Review by Code List PBCWA, Pg 515 Original policy |
| 93457 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 515 Original policy |
| 93458 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization | Clinical Review by Code List PBCWA, Pg 516 Original policy |
| 93459 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization | Clinical Review by Code List PBCWA, Pg 516 Original policy |
| 93460 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization | Clinical Review by Code List PBCWA, Pg 516 Original policy |
| 93461 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization | Clinical Review by Code List PBCWA, Pg 516 Original policy |
| 93580 | Percutaneous transcatheter closure of congenital interatrial communication (ie, fonton fenestration, atrial septal defect) with implant These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 516 Original policy |
| 93609 | Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 517 Original policy |
| 93613 | Intracardiac electrophysiologic 3- dimensional mapping (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 517 Original policy |
| 93619 | Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia | Clinical Review by Code List PBCWA, Pg 517 Original policy |
| 93620 | Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 517 Original policy |
| 93621 | Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 518 Original policy |
| 93622 | Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 518 Original policy |
| 93624 | Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction of arrhythmia | Clinical Review by Code List PBCWA, Pg 518 Original policy |