Premera Blue Cross of Washington prior authorization, page 41
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 |
|---|---|---|
| K0806 | Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 739 Original policy |
| K0807 | Power operated vehicle, group 2 heavy- duty, patient weight capacity 301 to 450 pounds | Clinical Review by Code List PBCWA, Pg 739 Original policy |
| K0808 | Power operated vehicle, group 2 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 739 Original policy |
| K0812 | Power operated vehicle, not otherwise classified | Clinical Review by Code List PBCWA, Pg 740 Original policy |
| K0813 | Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 740 Original policy |
| K0814 | Power wheelchair, group 1 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 740 Original policy |
| K0815 | Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 741 Original policy |
| K0816 | Power wheelchair, group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 741 Original policy |
| K0820 | Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 741 Original policy |
| K0821 | Power wheelchair, group 2 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 742 Original policy |
| K0822 | Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 742 Original policy |
| K0823 | Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 742 Original policy |
| K0824 | Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Clinical Review by Code List PBCWA, Pg 743 Original policy |
| K0825 | Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds | Clinical Review by Code List PBCWA, Pg 743 Original policy |
| K0826 | Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 743 Original policy |
| K0827 | Power wheelchair, group 2 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds | Clinical Review by Code List PBCWA, Pg 744 Original policy |
| K0828 | Power wheelchair, group 2 extra heavy- duty, sling/solid seat/back, patient weight capacity 601 pounds or more | Clinical Review by Code List PBCWA, Pg 744 Original policy |
| K0829 | Power wheelchair, group 2 extra heavy- duty, captain's chair, patient weight 601 pounds or more These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 744 Original policy |
| K0835 | Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 745 Original policy |
| K0836 | Power wheelchair, group 2 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 745 Original policy |
| K0837 | Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 745 Original policy |
| K0838 | Power wheelchair, group 2 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds | Clinical Review by Code List PBCWA, Pg 746 Original policy |
| K0839 | Power wheelchair, group 2 very heavy-duty, single power option sling/solid seat/back, patient weight capacity 451 to 600 pounds | Clinical Review by Code List PBCWA, Pg 746 Original policy |
| K0840 | Power wheelchair, group 2 extra heavy- duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 746 Original policy |
| K0841 | Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 747 Original policy |
| K0842 | Power wheelchair, group 2 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 747 Original policy |
| K0843 | Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 747 Original policy |
| K0848 | Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 748 Original policy |
| K0849 | Power wheelchair, group 3 standard, captain's chair, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 748 Original policy |
| K0850 | Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 748 Original policy |
| K0851 | Power wheelchair, group 3 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds | Clinical Review by Code List PBCWA, Pg 749 Original policy |
| K0852 | Power wheelchair, group 3 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Clinical Review by Code List PBCWA, Pg 749 Original policy |
| K0853 | Power wheelchair, group 3 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 749 Original policy |
| K0854 | Power wheelchair, group 3 extra heavy- duty, sling/solid seat/back, patient weight capacity 601 pounds or more | Clinical Review by Code List PBCWA, Pg 750 Original policy |
| K0855 | Power wheelchair, group 3 extra heavy duty, captain's chair, patient weight capacity 601 pounds or more | Clinical Review by Code List PBCWA, Pg 750 Original policy |
| K0856 | Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 750 Original policy |
| K0857 | Power wheelchair, group 3 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 751 Original policy |
| K0858 | Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds | Clinical Review by Code List PBCWA, Pg 751 Original policy |
| K0859 | Power wheelchair, group 3 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 751 Original policy |
| K0860 | Power wheelchair, group 3 very heavy-duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Clinical Review by Code List PBCWA, Pg 752 Original policy |
| K0861 | Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 752 Original policy |
| K0862 | Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 752 Original policy |
| K0863 | Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Clinical Review by Code List PBCWA, Pg 753 Original policy |
| K0864 | Power wheelchair, group 3 extra heavy- duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more | Clinical Review by Code List PBCWA, Pg 753 Original policy |
| K0868 | Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 753 Original policy |
| K0869 | Power wheelchair, group 4 standard, captain's chair, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 754 Original policy |
| K0870 | Power wheelchair, group 4 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Clinical Review by Code List PBCWA, Pg 754 Original policy |
| K0871 | Power wheelchair, group 4 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 754 Original policy |
| K0877 | Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 755 Original policy |
| K0878 | Power wheelchair, group 4 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 755 Original policy |