Premera Blue Cross of Washington prior authorization, page 29
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 |
|---|---|---|
| 93655 | Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 518 Original policy |
| 93656 | Comprehensive electrophysiologic evaluation with transseptal catheterizations, insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, and intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3- dimensional mapping, intracardiac echocardiography with imaging supervision and interpretation, right ventricular pacing/recording, and His bundle recording, when performed | Clinical Review by Code List PBCWA, Pg 519 Original policy |
| 93657 | Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 519 Original policy |
| 95782 | Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 520 Original policy |
| 95783 | Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by technologist | Clinical Review by Code List PBCWA, Pg 521 Original policy |
| 95805 | Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness | Clinical Review by Code List PBCWA, Pg 521 Original policy |
| 95807 | Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist | Clinical Review by Code List PBCWA, Pg 521 Original policy |
| 95808 | Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist | Clinical Review by Code List PBCWA, Pg 521 Original policy |
| 95810 | Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 521 Original policy |
| 95811 | Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist | Clinical Review by Code List PBCWA, Pg 522 Original policy |
| 95965 | Magnetoencephalography (MEG) recording and analysis for spontaneous brain magnetic activity (eg epileptic cerebral cortex localization) | Clinical Review by Code List PBCWA, Pg 522 Original policy |
| 95966 | Magnetoencephalography (MEG) recording and analysis for evoked magnetic fields single modality (eg sensory motor language or visual cortex localization) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 522 Original policy |
| 96446 | Chemotherapy administration into the peritoneal cavity via implanted port or catheter These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 523 Original policy |
| 96547 | Intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) procedure, including separate incision(s) and closure, when performed; first 60 minutes | Clinical Review by Code List PBCWA, Pg 524 Original policy |
| 96548 | Intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) procedure, including separate incision(s) and closure, when performed; each additional 30 minutes | Clinical Review by Code List PBCWA, Pg 524 Original policy |
| 97605 | Negative pressure wound therapy (e.g., vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters | Clinical Review by Code List PBCWA, Pg 531 Original policy |
| 97606 | Negative pressure wound therapy (e.g., vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 531 Original policy |
| 97607 | Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters | Clinical Review by Code List PBCWA, Pg 532 Original policy |
| 97608 | Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters | Clinical Review by Code List PBCWA, Pg 532 Original policy |
| 99183 | Physician attendance and supervision of hyperbaric oxygen therapy, per session | Clinical Review by Code List PBCWA, Pg 534 Original policy |
| A4540 | Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm | Clinical Review by Code List PBCWA, Pg 544 Original policy |
| A4555 | Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 544 Original policy |
| A6550 | Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories | Clinical Review by Code List PBCWA, Pg 546 Original policy |
| A8005 | Powered, cable driven grip assist glove, hand, finger, includes microprocessor, pressure sensors, all components and accessories, custom fitted | Clinical Review by Code List PBCWA, Pg 551 Original policy |
| A8006 | Powered, cable driven grip assist glove, hand, finger, includes pressure sensors, glove replacement only | Clinical Review by Code List PBCWA, Pg 551 Original policy |
| A9513 | Lutetium lu 177, dotatate, therapeutic, 1 millicurie | Clinical Review by Code List PBCWA, Pg 552 Original policy |
| A9574 | INJECTION, FERUMOXYTOL, 1 MG | Clinical Review by Code List PBCWA, Pg 552 Original policy |
| A9584 | Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 millicuries These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 552 Original policy |
| A9607 | Lutetium Lu 177 vipivotide tetraxetan, therapeutic, 1 mCi | Clinical Review by Code List PBCWA, Pg 553 Original policy |
| A9613 | Piflufolastaf F 18, diagnostic, 1 mCi (Pylarify Truvu) | Clinical Review by Code List PBCWA, Pg 553 Original policy |
| C1817 | Septal defect implant system, intracardiac | Clinical Review by Code List PBCWA, Pg 560 Original policy |
| D0364 | Cone beam CT capture and interpretation with limited field of view - less than one whole jaw | Clinical Review by Code List PBCWA, Pg 585 Original policy |
| D0365 | Cone beam CT capture and interpretation with field of view of one full dental arch - mandible These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 585 Original policy |
| D0366 | Cone beam CT capture and interpretation with field of view of one full dental arch - maxilla, with or without cranium | Clinical Review by Code List PBCWA, Pg 586 Original policy |
| D0367 | Cone beam CT capture and interpretation with field of view of both jaws; with or without cranium | Clinical Review by Code List PBCWA, Pg 586 Original policy |
| D0368 | Cone beam CT capture and interpretation for TMJ series including two or more exposures | Clinical Review by Code List PBCWA, Pg 586 Original policy |
| D0369 | Maxillofacial MRI capture and interpretation These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 586 Original policy |
| D0380 | Cone beam CT image capture with limited field of view - less than one whole jaw | Clinical Review by Code List PBCWA, Pg 587 Original policy |
| D0381 | Cone beam CT image capture with field of view of one full dental arch - mandible | Clinical Review by Code List PBCWA, Pg 587 Original policy |
| D0382 | Cone beam CT image capture with field of view of one full dental arch - maxilla, with or without cranium These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 587 Original policy |
| D0383 | Cone beam CT image capture with field of view of both jaws, with or without cranium | Clinical Review by Code List PBCWA, Pg 588 Original policy |
| D0384 | Cone beam CT image capture for TMJ series including two or more exposures | Clinical Review by Code List PBCWA, Pg 588 Original policy |
| D0385 | Maxillofacial MRI image capture | Clinical Review by Code List PBCWA, Pg 588 Original policy |
| D7830 | Manipulation under anesthesia | Clinical Review by Code List PBCWA, Pg 629 Original policy |
| D7840 | Condylectomy | Clinical Review by Code List PBCWA, Pg 629 Original policy |
| D8010 | Limited orthodontic treatment of the primary dentition These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 634 Original policy |
| D8020 | Limited orthodontic treatment of the transitional dentition | Clinical Review by Code List PBCWA, Pg 635 Original policy |
| D8030 | Limited orthodontic treatment of the adolescent dentition These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 635 Original policy |
| D8040 | Limited orthodontic treatment of the adult dentition | Clinical Review by Code List PBCWA, Pg 636 Original policy |
| D8070 | Comprehensive orthodontic treatment of the transitional dentition These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 636 Original policy |