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Premera Blue Cross of Washington prior authorization, page 40

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

Prior authorization codes
CodeDescriptionSource
J9323Injection, pemetrexed (hospira) not therapeutically equivalent to j9305, 10 mgClinical Review by Code List PBCWA, Pg 730 Original policy
J9324Injection, pemetrexed (pemrydi rtu), 10 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 730 Original policy
J9326Injection, telisotuzumab vedotin-tllv, 1 mgClinical Review by Code List PBCWA, Pg 731 Original policy
J9328Injection, temozolomide, 1 mgClinical Review by Code List PBCWA, Pg 731 Original policy
J9329Injection, tislelizumab-jsgr, 1mgClinical Review by Code List PBCWA, Pg 731 Original policy
J9330Injection, temsirolimus, 1 mg (Torisel)Clinical Review by Code List PBCWA, Pg 731 Original policy
J9331Injection, sirolimus protein-bound particles, 1 mgClinical Review by Code List PBCWA, Pg 731 Original policy
J9332Injection, efgartigimod alfa-fcab, 2 mgClinical Review by Code List PBCWA, Pg 731 Original policy
J9333Injection, rozanolixizumab-noli, 1 mgClinical Review by Code List PBCWA, Pg 731 Original policy
J9334Injection, efgartigimod alfa, 2 mg and hyaluronidase-qvfcClinical Review by Code List PBCWA, Pg 731 Original policy
J9341Injection, thiotepa (Tepylute), 1 mgClinical Review by Code List PBCWA, Pg 731 Original policy
J9345Injection, Retifanlimab-DLWR, 1 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 731 Original policy
J9347Injection, tremelimumab-actl, 1 mgClinical Review by Code List PBCWA, Pg 732 Original policy
J9348Injection, naxitamab-gqgk, 1 mgClinical Review by Code List PBCWA, Pg 732 Original policy
J9349Injection, tafasitamab-cxix, 2 mgClinical Review by Code List PBCWA, Pg 732 Original policy
J9350Injection, mosunetuzumab-axgb, 1 mgClinical Review by Code List PBCWA, Pg 732 Original policy
J9353Injection, margetuximab-cmkb, 5 mgClinical Review by Code List PBCWA, Pg 732 Original policy
J9354Injection, ado-trastuzumab emtansine, 1 mgClinical Review by Code List PBCWA, Pg 732 Original policy
J9355Injection, trastuzumab, excludes biosimilar, 10 mgClinical Review by Code List PBCWA, Pg 732 Original policy
J9356Injection, bendamustine hydrochloride, (Belrapzo/bendamustine), 1 mgClinical Review by Code List PBCWA, Pg 732 Original policy
J9358Injection, fam-trastuzumab deruxtecan-nxki, 1 mgClinical Review by Code List PBCWA, Pg 732 Original policy
J9359Injection, loncastuximab tesirine-lpyl, 0.075 mgClinical Review by Code List PBCWA, Pg 732 Original policy
J9361Injection, efbemalenograstim alfa-vuxw, 0.5 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 732 Original policy
J9376Injection, pozelimab-bbfg, 1 mgClinical Review by Code List PBCWA, Pg 733 Original policy
J9380Injection, Teclistamab-cqyv, 0.5 mgClinical Review by Code List PBCWA, Pg 733 Original policy
J9381Injection, teplizumab-mzwv, 5 mcgClinical Review by Code List PBCWA, Pg 733 Original policy
J9382Injection, zenocutuzumab-zbco, 1 mgClinical Review by Code List PBCWA, Pg 733 Original policy
J9395Injection, fulvestrant, 25 mgClinical Review by Code List PBCWA, Pg 733 Original policy
J9400Injection, ziv-aflibercept, 1 mgClinical Review by Code List PBCWA, Pg 733 Original policy
J9601Injection, linvoseltamab-gcpt, 1 mgClinical Review by Code List PBCWA, Pg 733 Original policy
J9999Not otherwise classified, antineoplastic drugsClinical Review by Code List PBCWA, Pg 733 Original policy
K0004High strength, lightweight wheelchair These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 733 Original policy
K0005Ultralight weight wheelchairClinical Review by Code List PBCWA, Pg 734 Original policy
K0008Custom manual wheelchair baseClinical Review by Code List PBCWA, Pg 734 Original policy
K0009Other manual wheelchair/base These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 734 Original policy
K0010Standard - weight frame motorized/power wheelchairClinical Review by Code List PBCWA, Pg 735 Original policy
K0011Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and brakingClinical Review by Code List PBCWA, Pg 735 Original policy
K0012Lightweight portable motorized/power wheelchair These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 735 Original policy
K0013Custom motorized/power wheelchair baseClinical Review by Code List PBCWA, Pg 736 Original policy
K0014Other motorized/power wheelchair baseClinical Review by Code List PBCWA, Pg 736 Original policy
K0108Wheelchair component or accessory, not otherwise specifiedClinical Review by Code List PBCWA, Pg 736 Original policy
K0606Automatic external defibrillator, with integrated electrocardiogram analysis, garment typeClinical Review by Code List PBCWA, Pg 736 Original policy
K0669Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or no written coding verification from SADMERCClinical Review by Code List PBCWA, Pg 737 Original policy
K0743Suction pump, home model, portable, for use on woundsClinical Review by Code List PBCWA, Pg 737 Original policy
K0744Absorptive wound dressing for use with suction pump, home model, portable, pad size 16 square inches or lessClinical Review by Code List PBCWA, Pg 737 Original policy
K0745Absorptive wound dressing for use with suction pump, home model, portable, pad size more than 16 square inches but less than or equal to 48 square inchesClinical Review by Code List PBCWA, Pg 737 Original policy
K0746Absorptive wound dressing for use with suction pump, home model, portable, pad size greater than 48 square inches These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 737 Original policy
K0800Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 poundsClinical Review by Code List PBCWA, Pg 738 Original policy
K0801Power operated vehicle, group 1 heavy- duty, patient weight capacity 301 to 450 poundsClinical Review by Code List PBCWA, Pg 738 Original policy
K0802Power operated vehicle, group 1 very heavy-duty, patient weight capacity 451 to 600 pounds These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 738 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.

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