Premera Blue Cross of Washington prior authorization, page 33
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 |
|---|---|---|
| G0277 | Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 683 Original policy |
| G0330 | Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating room | Clinical Review by Code List PBCWA, Pg 685 Original policy |
| G0339 | Image guided robotic linear accelerator- based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment | Clinical Review by Code List PBCWA, Pg 685 Original policy |
| G0340 | Image guided robotic linear accelerator- based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment | Clinical Review by Code List PBCWA, Pg 685 Original policy |
| G0341 | Percutaneous islet cell transplant, includes portal vein catheterization and infusion These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 685 Original policy |
| G0342 | Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion | Clinical Review by Code List PBCWA, Pg 686 Original policy |
| G0343 | Laparotomy for islet cell transplant, includes portal vein catheterization and infusion | Clinical Review by Code List PBCWA, Pg 686 Original policy |
| G0458 | Low dose rate (LDR) prostate brachytherapy services, composite rate | Clinical Review by Code List PBCWA, Pg 686 Original policy |
| G0465 | Autologous platelet rich plasma (PRP) or other blood-derived product for diabetic chronic wounds/ulcers, using an FDA- cleared device for this indication, (includes, as applicable: administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment) | Clinical Review by Code List PBCWA, Pg 687 Original policy |
| G2082 | Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self administration, includes 2 hours post administration observation | Clinical Review by Code List PBCWA, Pg 689 Original policy |
| G2083 | Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg esketamine nasal self administration, includes 2 hours post administration observation | Clinical Review by Code List PBCWA, Pg 689 Original policy |
| G9143 | Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s) | Clinical Review by Code List PBCWA, Pg 689 Original policy |
| J0013 | Esketamine, nasal spary (Spravato), 1 mg These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 694 Original policy |
| J0129 | Injection, abatacept, 10 mg | Clinical Review by Code List PBCWA, Pg 695 Original policy |
| J0139 | Injection, adalimumab, 1 mg | Clinical Review by Code List PBCWA, Pg 695 Original policy |
| J0174 | Lecanemab-irmb, for intravenous injection, 1 mg | Clinical Review by Code List PBCWA, Pg 695 Original policy |
| J0175 | Injection, donanemab-azbt, 2 mg | Clinical Review by Code List PBCWA, Pg 695 Original policy |
| J0177 | Injection, aflibercept HD, 1 mg | Clinical Review by Code List PBCWA, Pg 695 Original policy |
| J0178 | Injection, aflibercept, 1 mg (Eylea) | Clinical Review by Code List PBCWA, Pg 695 Original policy |
| J0179 | Injection, brolucizumab-dbll, 1 mg | Clinical Review by Code List PBCWA, Pg 695 Original policy |
| J0180 | Injection, agalsidase beta, 1 mg | Clinical Review by Code List PBCWA, Pg 695 Original policy |
| J0202 | Injection, Alemtuzumab, 1 MG | Clinical Review by Code List PBCWA, Pg 695 Original policy |
| J0217 | Injection, velmanase alfa-tycv, 1 mg | Clinical Review by Code List PBCWA, Pg 695 Original policy |
| J0218 | Injection, Olipudase alfa-rpcp, 1 mg These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 695 Original policy |
| J0219 | Injection, avalglucosidase alfa-ngpt, 4 mg | Clinical Review by Code List PBCWA, Pg 696 Original policy |
| J0221 | Injection, alglucosidase alfa, (Lumizyme), 10 mg | Clinical Review by Code List PBCWA, Pg 696 Original policy |
| J0222 | Injection, patisiran, 0.1 mg | Clinical Review by Code List PBCWA, Pg 696 Original policy |
| J0223 | Injection, givosiran, 0.5 mg | Clinical Review by Code List PBCWA, Pg 696 Original policy |
| J0224 | Injection, lumasiran, 0.5 mg | Clinical Review by Code List PBCWA, Pg 696 Original policy |
| J0225 | Injection, vutrisiran, 1 mg | Clinical Review by Code List PBCWA, Pg 696 Original policy |
| J0248 | Injection, remdesivir, 1 mg | Clinical Review by Code List PBCWA, Pg 696 Original policy |
| J0256 | Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 696 Original policy |
| J0257 | Injection, alpha 1 proteinase inhibitor (human), (GLASSIA), 10 mg | Clinical Review by Code List PBCWA, Pg 697 Original policy |
| J0364 | Injection, apomorphine HCl, 1 mg | Clinical Review by Code List PBCWA, Pg 697 Original policy |
| J0485 | Injection, belatacept, 1 mg | Clinical Review by Code List PBCWA, Pg 697 Original policy |
| J0490 | Injection, belimumab, 10 mg | Clinical Review by Code List PBCWA, Pg 697 Original policy |
| J0491 | Injection, anifrolumab-fnia, 1 mg | Clinical Review by Code List PBCWA, Pg 697 Original policy |
| J0517 | Injection, benralizumab, 1 mg | Clinical Review by Code List PBCWA, Pg 697 Original policy |
| J0565 | Injection, bezlotoxumab, 10 mg | Clinical Review by Code List PBCWA, Pg 697 Original policy |
| J0567 | Injection, cerliponase alfa, 1 mg These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 697 Original policy |
| J0584 | Injection, burosumab-twza 1 mg | Clinical Review by Code List PBCWA, Pg 698 Original policy |
| J0585 | Injection, onabotulinumtoxinA, 1 unit | Clinical Review by Code List PBCWA, Pg 698 Original policy |
| J0586 | Injection, abobotulinumtoxinA, 5 units | Clinical Review by Code List PBCWA, Pg 698 Original policy |
| J0587 | Injection, rimabotulinumtoxinB, 100 units | Clinical Review by Code List PBCWA, Pg 698 Original policy |
| J0588 | Injection, incobotulinumtoxinA, 1 unit | Clinical Review by Code List PBCWA, Pg 698 Original policy |
| J0589 | Injection, Daxibotulinumtoxina-lanm, 1 unit | Clinical Review by Code List PBCWA, Pg 698 Original policy |
| J0593 | Injection, lanadelumab-flyo, 1 mg (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self- administered) | Clinical Review by Code List PBCWA, Pg 698 Original policy |
| J0596 | Injection, C1 esterase inhibitor (recombinant), Ruconest, 10 units | Clinical Review by Code List PBCWA, Pg 698 Original policy |
| J0597 | Injection, C-1 esterase inhibitor (human), Berinert, 10 units | Clinical Review by Code List PBCWA, Pg 698 Original policy |
| J0598 | Injection, C-1 esterase inhibitor (human), Cinryze, 10 units These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 698 Original policy |