Premera Blue Cross of Washington prior authorization, page 31
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 |
|---|---|---|
| E0655 | Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm | Clinical Review by Code List PBCWA, Pg 652 Original policy |
| E0656 | Segmental pneumatic appliance for use with pneumatic compressor, trunk | Clinical Review by Code List PBCWA, Pg 652 Original policy |
| E0657 | Segmental pneumatic appliance for use with pneumatic compressor, chest These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 652 Original policy |
| E0658 | Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full arms and chest | Clinical Review by Code List PBCWA, Pg 653 Original policy |
| E0665 | Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm | Clinical Review by Code List PBCWA, Pg 653 Original policy |
| E0666 | Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg | Clinical Review by Code List PBCWA, Pg 653 Original policy |
| E0667 | Segmental pneumatic appliance for use with pneumatic compressor, full leg | Clinical Review by Code List PBCWA, Pg 653 Original policy |
| E0670 | Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk | Clinical Review by Code List PBCWA, Pg 653 Original policy |
| E0673 | Segmental gradient pressure pneumatic appliance, half leg | Clinical Review by Code List PBCWA, Pg 653 Original policy |
| E0678 | Non-pneumatic sequential compression garment, full leg | Clinical Review by Code List PBCWA, Pg 653 Original policy |
| E0679 | Non-pneumatic sequential compression garment, half leg | Clinical Review by Code List PBCWA, Pg 653 Original policy |
| E0680 | Non-pneumatic compression controller with sequential calibrated gradient pressure These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 653 Original policy |
| E0681 | Non-pneumatic compression controller without calibrated gradient pressure | Clinical Review by Code List PBCWA, Pg 654 Original policy |
| E0682 | Non-pneumatic sequential compression garment, full arm | Clinical Review by Code List PBCWA, Pg 654 Original policy |
| E0745 | Neuromuscular stimulator, electronic shock unit | Clinical Review by Code List PBCWA, Pg 655 Original policy |
| E0747 | Osteogenesis stimulator, electrical, noninvasive, other than spinal applications These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 655 Original policy |
| E0748 | Osteogenic stimulator, electrical, non- invasive, spinal applications | Clinical Review by Code List PBCWA, Pg 656 Original policy |
| E0749 | Osteogenesis stimulator, electrical, surgically implanted | Clinical Review by Code List PBCWA, Pg 656 Original policy |
| E0760 | Osteogenesis stimulator, low intensity ultrasound, non-invasive | Clinical Review by Code List PBCWA, Pg 656 Original policy |
| E0761 | Nonthermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device | Clinical Review by Code List PBCWA, Pg 656 Original policy |
| E0766 | Electrical stimulation device used for cancer treatment, includes all accessories, any type | Clinical Review by Code List PBCWA, Pg 657 Original policy |
| E0983 | Manual wheelchair accessory, power add- on to convert manual wheelchair to motorized wheelchair, joystick control | Clinical Review by Code List PBCWA, Pg 658 Original policy |
| E0984 | Power add-on to convert manual wheelchair to motorized wheelchair, tiller cotnrol | Clinical Review by Code List PBCWA, Pg 658 Original policy |
| E0986 | Manual wheelchair accessory, power assist system | Clinical Review by Code List PBCWA, Pg 658 Original policy |
| E0988 | Manual wheelchair accessory, lever- activated, wheel drive, pair | Clinical Review by Code List PBCWA, Pg 658 Original policy |
| E1002 | Power seating system, tilt only | Clinical Review by Code List PBCWA, Pg 658 Original policy |
| E1003 | Wheelchair accessory, power seating system, recline only, without shear reduction | Clinical Review by Code List PBCWA, Pg 658 Original policy |
| E1004 | Wheelchair accessory, power seating system, recline only, with mechanical shear reduction These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 658 Original policy |
| E1005 | Wheelchair accessory, power seatng System, recline only, with power shear reduction | Clinical Review by Code List PBCWA, Pg 659 Original policy |
| E1006 | Power seating system, combination tilt and recline, without shear reduction | Clinical Review by Code List PBCWA, Pg 659 Original policy |
| E1007 | Power seating system, combination tilt and recline, with mechanical sheer reduction | Clinical Review by Code List PBCWA, Pg 659 Original policy |
| E1008 | Power seating system, combination tilt and recline, with power shear reduction | Clinical Review by Code List PBCWA, Pg 659 Original policy |
| E1009 | Addition to power seating system, mechanically linked leg elevation system, including pushrod and leg rest, each | Clinical Review by Code List PBCWA, Pg 659 Original policy |
| E1010 | Addition to power seating system, power leg elevation system, including leg rest, pair | Clinical Review by Code List PBCWA, Pg 659 Original policy |
| E1012 | Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each | Clinical Review by Code List PBCWA, Pg 659 Original policy |
| E1014 | Reclining back, addition to pediatric size wheelchair | Clinical Review by Code List PBCWA, Pg 659 Original policy |
| E1035 | Multi-positional patient transfer system, with integrated seat, operated by care giver, patient weight capacity up to and including 300 lbs | Clinical Review by Code List PBCWA, Pg 660 Original policy |
| E1036 | Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 660 Original policy |
| E1050 | Fully-reclining wheelchair, fixed full-length arms, swing-away detachable elevating legrests | Clinical Review by Code List PBCWA, Pg 661 Original policy |
| E1060 | Fully-reclining wheelchair, detachable arms, desk or full-length, swing-away detachable elevating legrests These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 661 Original policy |
| E1070 | Fully-reclining wheelchair, detachable arms (desk or full-length) swing-away detachable footrest | Clinical Review by Code List PBCWA, Pg 662 Original policy |
| E1083 | Hemi-wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 662 Original policy |
| E1085 | Hemi-wheelchair, fixed full-length arms, swing-away detachable footrests These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 663 Original policy |
| E1086 | Hemi-wheelchair, detachable arms, desk or full-length, swing-away detachable footrests | Clinical Review by Code List PBCWA, Pg 664 Original policy |
| E1087 | High strength lightweight wheelchair, fixed full-length arms, swing-away detachable elevating legrests These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 664 Original policy |
| E1088 | High strength lightweight wheelchair, detachable arms desk or full-length, swing- away detachable elevating legrests | Clinical Review by Code List PBCWA, Pg 665 Original policy |
| E1089 | High-strength lightweight wheelchair, fixed- length arms, swing-away detachable footrest | Clinical Review by Code List PBCWA, Pg 665 Original policy |
| E1090 | High-strength lightweight wheelchair, detachable arms, desk or full-length, swing- away detachable footrests | Clinical Review by Code List PBCWA, Pg 665 Original policy |
| E1100 | Semi-reclining wheelchair, fixed full-length arms, swing-away detachable elevating legrests These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 665 Original policy |
| E1110 | Semi-reclining wheelchair, detachable arms (desk or full-length) elevating legrest | Clinical Review by Code List PBCWA, Pg 666 Original policy |