Premera Blue Cross of Washington prior authorization, page 32
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 |
|---|---|---|
| E1160 | Wheelchair, fixed full-length arms, swing- away, detachable, elevating legrests | Clinical Review by Code List PBCWA, Pg 666 Original policy |
| E1161 | Manual adult size wheelchair, includes tilt in space These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 666 Original policy |
| E1170 | Amputee wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests | Clinical Review by Code List PBCWA, Pg 667 Original policy |
| E1171 | Amputee wheelchair, fixed full-length arms, without footrests or legrest These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 667 Original policy |
| E1172 | Amputee wheelchair, detachable arms (desk or full-length) without footrests or legrest | Clinical Review by Code List PBCWA, Pg 668 Original policy |
| E1190 | Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable elevating legrests | Clinical Review by Code List PBCWA, Pg 669 Original policy |
| E1195 | Heavy duty 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 669 Original policy |
| E1200 | Amputee wheelchair; fixed full-length arms, swing-away, detachable footrests | Clinical Review by Code List PBCWA, Pg 670 Original policy |
| E1220 | Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification | Clinical Review by Code List PBCWA, Pg 670 Original policy |
| E1221 | Wheelchair with fixed arm, footrests These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 670 Original policy |
| E1223 | Wheelchair with detachable arms, footrests | Clinical Review by Code List PBCWA, Pg 671 Original policy |
| E1224 | Wheelchair with detachable arms, elevating legrests | Clinical Review by Code List PBCWA, Pg 671 Original policy |
| E1229 | Wheelchair, pediatric size, not otherwise specified These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 671 Original policy |
| E1230 | Power operated vehicle (three- or four- wheel nonhighway), specify brand name and model number | Clinical Review by Code List PBCWA, Pg 672 Original policy |
| E1231 | Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system | Clinical Review by Code List PBCWA, Pg 672 Original policy |
| E1232 | Wheelchair; Pediatric size, tilt-in-space, folding, adjustable, with seating system These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 672 Original policy |
| E1233 | Pediatric size, tilt-in-space, rigid, adjustable, without seating system | Clinical Review by Code List PBCWA, Pg 673 Original policy |
| E1234 | Pediatric size, tilt-in-space, folding adjustable with seating system | Clinical Review by Code List PBCWA, Pg 673 Original policy |
| E1235 | Pediatric size, folding, adjustable, with seating system These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 673 Original policy |
| E1236 | Wheelchair, pediatric size, folding, adjustable, with seating system | Clinical Review by Code List PBCWA, Pg 674 Original policy |
| E1237 | Pediatric size, rigid, adjustable, without seating system | Clinical Review by Code List PBCWA, Pg 674 Original policy |
| E1238 | Pediatric size, folding, adjustable, without seating system These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 674 Original policy |
| E1240 | Lightweight wheelchair, detachable arms, (desk or full-length) swing-away detachable, elevating legrest | Clinical Review by Code List PBCWA, Pg 675 Original policy |
| E1250 | Lightweight wheelchair, fixed full-length arms, swing-away detachable footrest These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 675 Original policy |
| E1260 | Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest | Clinical Review by Code List PBCWA, Pg 676 Original policy |
| E1270 | 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 676 Original policy |
| E1280 | Heavy duty wheelchair; detachable arms, desk or full-length, elevating legrests | Clinical Review by Code List PBCWA, Pg 677 Original policy |
| E1285 | Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 677 Original policy |
| E1290 | Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest | Clinical Review by Code List PBCWA, Pg 678 Original policy |
| E1295 | Heavy-duty wheelchair, fixed full-length arms, elevating legrest | Clinical Review by Code List PBCWA, Pg 678 Original policy |
| E2227 | Manual wheelchair accessory, gear reduction drive wheel, each | Clinical Review by Code List PBCWA, Pg 679 Original policy |
| E2230 | Manual wheelchair accessory, manual standing system | Clinical Review by Code List PBCWA, Pg 679 Original policy |
| E2292 | Seat, planar, for pediatric size wheelchair including fixed attaching hardware These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 679 Original policy |
| E2295 | Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning features | Clinical Review by Code List PBCWA, Pg 680 Original policy |
| E2331 | Power wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting hardware | Clinical Review by Code List PBCWA, Pg 680 Original policy |
| E2341 | Power wheelchair accessory, nonstandard seat frame width, 24-27 in | Clinical Review by Code List PBCWA, Pg 680 Original policy |
| E2342 | Non-standard seat frame depth, 20 or 21 inches | Clinical Review by Code List PBCWA, Pg 680 Original policy |
| E2343 | Power wheelchair accessory, nonstandard seat frame depth, 22-25 in | Clinical Review by Code List PBCWA, Pg 680 Original policy |
| E2351 | Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface | Clinical Review by Code List PBCWA, Pg 680 Original policy |
| E2398 | Wheelchair accessory, dynamic positioning hardware for back | Clinical Review by Code List PBCWA, Pg 681 Original policy |
| E2402 | Negative pressure wound therapy electrical pump, stationary or portable | Clinical Review by Code List PBCWA, Pg 681 Original policy |
| E2609 | Custom fabricated wheelchair seat cushion, any size | Clinical Review by Code List PBCWA, Pg 681 Original policy |
| E2610 | Wheelchair seat cushion, powered | Clinical Review by Code List PBCWA, Pg 681 Original policy |
| E2617 | Custom fabricated wheelchair back cushion, any size, includes any type mounting hardware | Clinical Review by Code List PBCWA, Pg 681 Original policy |
| E2620 | Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in., any height, including any type mounting hardware | Clinical Review by Code List PBCWA, Pg 681 Original policy |
| E2621 | Positioning wheelchair back cushion, planar back with lateral supports, width 22 in or greater, any height, including any type mounting hardware | Clinical Review by Code List PBCWA, Pg 681 Original policy |
| E2622 | Skin protection wheelchair seat cushion, adjustable, width less than 22 in, any depth | Clinical Review by Code List PBCWA, Pg 681 Original policy |
| E2623 | Skin protection wheelchair seat cushion, adjustable, width 22 in or greater, any depth These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 681 Original policy |
| G0219 | PET imaging whole body; melanoma for noncovered indications | Clinical Review by Code List PBCWA, Pg 683 Original policy |
| G0252 | PET imaging, full and partial-ring PET scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes) | Clinical Review by Code List PBCWA, Pg 683 Original policy |