Premera Blue Cross of Washington prior authorization, page 30
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 |
|---|---|---|
| D8080 | Comprehensive orthodontic treatment of the adolescent dentition | Clinical Review by Code List PBCWA, Pg 637 Original policy |
| D8090 | Comprehensive orthodontic treatment of the adult dentition These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 637 Original policy |
| D8210 | Removable appliance therapy | Clinical Review by Code List PBCWA, Pg 638 Original policy |
| D8220 | Fixed appliance therapy | Clinical Review by Code List PBCWA, Pg 638 Original policy |
| D8999 | Unspecified orthodontic procedure, by report | Clinical Review by Code List PBCWA, Pg 638 Original policy |
| D9947 | CUSTOM SLEEP APNEA APPLIANCE FABRICATION AND PLACEMENT | Clinical Review by Code List PBCWA, Pg 639 Original policy |
| E0193 | Powered air flotation bed (low air loss therapy) | Clinical Review by Code List PBCWA, Pg 641 Original policy |
| E0194 | Air fluidized bed | Clinical Review by Code List PBCWA, Pg 641 Original policy |
| E0250 | Hospital bed, fixed height, with any type side rails, with mattress | Clinical Review by Code List PBCWA, Pg 642 Original policy |
| E0251 | Hospital bed, fixed height, with any type side rails, without mattress | Clinical Review by Code List PBCWA, Pg 642 Original policy |
| E0255 | Hospital bed, variable height, hi-lo, with any type side rails, with mattress | Clinical Review by Code List PBCWA, Pg 642 Original policy |
| E0256 | Hospital bed, variable height, hi-lo, with any type side rails, without mattress These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 642 Original policy |
| E0260 | Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress | Clinical Review by Code List PBCWA, Pg 643 Original policy |
| E0261 | Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress | Clinical Review by Code List PBCWA, Pg 643 Original policy |
| E0265 | Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress | Clinical Review by Code List PBCWA, Pg 643 Original policy |
| E0266 | Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress | Clinical Review by Code List PBCWA, Pg 643 Original policy |
| E0270 | Hospital bed, institutional type includes: oscillating, circulating and Stryker frame, with mattress | Clinical Review by Code List PBCWA, Pg 643 Original policy |
| E0277 | Powered pressure-reducing air mattress | Clinical Review by Code List PBCWA, Pg 644 Original policy |
| E0290 | Hospital bed, fixed height, without side rails, with mattress | Clinical Review by Code List PBCWA, Pg 644 Original policy |
| E0291 | Hospital bed, fixed height, without side rails, without mattress | Clinical Review by Code List PBCWA, Pg 644 Original policy |
| E0292 | Hospital bed, variable height, hi-lo, without side rails, with mattress | Clinical Review by Code List PBCWA, Pg 644 Original policy |
| E0293 | Hospital bed, variable height, hi-lo, without side rails, without mattress These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 644 Original policy |
| E0294 | Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress | Clinical Review by Code List PBCWA, Pg 645 Original policy |
| E0295 | Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress | Clinical Review by Code List PBCWA, Pg 645 Original policy |
| E0296 | Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress | Clinical Review by Code List PBCWA, Pg 645 Original policy |
| E0297 | Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress | Clinical Review by Code List PBCWA, Pg 645 Original policy |
| E0300 | Pediatric crib, hospital grade, fully enclosed, with or without top enclosure | Clinical Review by Code List PBCWA, Pg 645 Original policy |
| E0301 | Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress | Clinical Review by Code List PBCWA, Pg 645 Original policy |
| E0302 | Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 645 Original policy |
| E0303 | Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress | Clinical Review by Code List PBCWA, Pg 646 Original policy |
| E0304 | Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress | Clinical Review by Code List PBCWA, Pg 646 Original policy |
| E0328 | Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress | Clinical Review by Code List PBCWA, Pg 646 Original policy |
| E0329 | Hospital bed, pediatric, electric or semi- electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress | Clinical Review by Code List PBCWA, Pg 646 Original policy |
| E0371 | Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 646 Original policy |
| E0372 | Powered air overlay for mattress, standard mattress length and width | Clinical Review by Code List PBCWA, Pg 647 Original policy |
| E0373 | Nonpowered advanced pressure reducing mattress | Clinical Review by Code List PBCWA, Pg 647 Original policy |
| E0481 | Intrapulmonary percussive ventilation system and related accessories These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 647 Original policy |
| E0483 | High frequency chest wall oscillation system, with full anterior and/or posterior thoracic region receiving simultaneous external oscillation, includes all accessories and supplies, each | Clinical Review by Code List PBCWA, Pg 648 Original policy |
| E0484 | Oscillatory positive expiratory pressure device, nonelectric, any type, each | Clinical Review by Code List PBCWA, Pg 648 Original policy |
| E0485 | Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment | Clinical Review by Code List PBCWA, Pg 648 Original policy |
| E0486 | Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment | Clinical Review by Code List PBCWA, Pg 648 Original policy |
| E0616 | Implantable cardiac event recorder with memory, activator, and programmer | Clinical Review by Code List PBCWA, Pg 650 Original policy |
| E0621 | Sling or seat, patient lift, canvas or nylon | Clinical Review by Code List PBCWA, Pg 650 Original policy |
| E0629 | Seat lift mechanism, nonelectric, any type | Clinical Review by Code List PBCWA, Pg 651 Original policy |
| E0630 | Patient lift; hydraulic or mechanical, includes any seat, sling, strap(s), or pad(s) | Clinical Review by Code List PBCWA, Pg 651 Original policy |
| E0638 | Standing frame system, one position (e.g., upright, supine or prone stander), any size including pediatric, with or without wheels | Clinical Review by Code List PBCWA, Pg 651 Original policy |
| E0639 | Patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 651 Original policy |
| E0641 | Standing frame system, multi-position (e.g., three-way stander,), any size including pediatric, with or without wheels | Clinical Review by Code List PBCWA, Pg 652 Original policy |
| E0642 | Standing frame system, mobile (dynamic stander), any size including pediatric | Clinical Review by Code List PBCWA, Pg 652 Original policy |
| E0652 | Pneumatic compressor, segmental home model with calibrated gradient pressure | Clinical Review by Code List PBCWA, Pg 652 Original policy |