Premera Blue Cross of Washington prior authorization, page 42
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 |
|---|---|---|
| K0879 | Power wheelchair, group 4 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 755 Original policy |
| K0880 | Power wheelchair, group 4 very heavy-duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds | Clinical Review by Code List PBCWA, Pg 756 Original policy |
| K0884 | Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Clinical Review by Code List PBCWA, Pg 756 Original policy |
| K0885 | Power wheelchair, group 4 standard, multiple power option, 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 756 Original policy |
| K0886 | Power wheelchair, group 4 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Clinical Review by Code List PBCWA, Pg 757 Original policy |
| K0890 | Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds | Clinical Review by Code List PBCWA, Pg 757 Original policy |
| K0891 | Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 757 Original policy |
| K0898 | Power wheelchair, not otherwise classified | Clinical Review by Code List PBCWA, Pg 758 Original policy |
| K0899 | Power mobility device, not coded by DME PDAC or does not meet criteria | Clinical Review by Code List PBCWA, Pg 758 Original policy |
| K0900 | Customized durable medical equipment, other than wheelchair | Clinical Review by Code List PBCWA, Pg 758 Original policy |
| K1027 | Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment | Clinical Review by Code List PBCWA, Pg 759 Original policy |
| L1834 | Knee orthotic (KO), without knee joint, rigid, custom fabricated | Clinical Review by Code List PBCWA, Pg 759 Original policy |
| L1840 | Derotation, medial-lateral, anterior cruciate ligament, custom-fabricated These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 759 Original policy |
| L1844 | Knee orthotic (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated | Clinical Review by Code List PBCWA, Pg 760 Original policy |
| L1846 | Knee orthotic, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial- lateral and rotation control, with or without varus/valgus adjustment, custom fabricated | Clinical Review by Code List PBCWA, Pg 760 Original policy |
| L1860 | Knee orthosis, modification of supracondylar prosthetic socket, custom fabricated (SK) | Clinical Review by Code List PBCWA, Pg 760 Original policy |
| L1945 | Ankle-foot orthotic (AFO), plastic, rigid anterior tibial section (floor reaction), custom fabricated | Clinical Review by Code List PBCWA, Pg 760 Original policy |
| L2755 | Addition to lower extremity orthotic, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthotic only | Clinical Review by Code List PBCWA, Pg 761 Original policy |
| L5615 | Additional, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control | Clinical Review by Code List PBCWA, Pg 761 Original policy |
| L5856 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type | Clinical Review by Code List PBCWA, Pg 761 Original policy |
| L5857 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type | Clinical Review by Code List PBCWA, Pg 761 Original policy |
| L5858 | Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 761 Original policy |
| L6026 | Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s) | Clinical Review by Code List PBCWA, Pg 762 Original policy |
| L6715 | Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 762 Original policy |
| L6880 | Electric hand, switch or myolelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) | Clinical Review by Code List PBCWA, Pg 763 Original policy |
| L6882 | Microprocessor control feature, addition to upper limb prosthetic terminal device | Clinical Review by Code List PBCWA, Pg 763 Original policy |
| L6895 | Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated | Clinical Review by Code List PBCWA, Pg 763 Original policy |
| L6925 | Wrist disarticulation, external power, self- suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device | Clinical Review by Code List PBCWA, Pg 763 Original policy |
| L6935 | Below elbow, external power, self- suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device | Clinical Review by Code List PBCWA, Pg 763 Original policy |
| L6945 | Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 763 Original policy |
| L6955 | Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device | Clinical Review by Code List PBCWA, Pg 764 Original policy |
| L6965 | Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device | Clinical Review by Code List PBCWA, Pg 764 Original policy |
| L6975 | Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device | Clinical Review by Code List PBCWA, Pg 764 Original policy |
| L7007 | Electric hand, switch or myoelectric controlled, adult | Clinical Review by Code List PBCWA, Pg 764 Original policy |
| L7008 | Electric hand, switch or myoelectric, controlled, pediatric | Clinical Review by Code List PBCWA, Pg 764 Original policy |
| L7009 | Electric hook, switch or myoelectric controlled, adult | Clinical Review by Code List PBCWA, Pg 764 Original policy |
| L7045 | Electric hook, switch or myoelectric controlled, pediatric These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 764 Original policy |
| L7180 | Electronic elbow, microprocessor sequential control of elbow and terminal device | Clinical Review by Code List PBCWA, Pg 765 Original policy |
| L7181 | Electronic elbow, microprocessor simultaneous control of elbow and terminal device | Clinical Review by Code List PBCWA, Pg 765 Original policy |
| L7190 | Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled | Clinical Review by Code List PBCWA, Pg 765 Original policy |
| L7191 | Electronic elbow, child, Variety Village or equal, myoelectronically controlled | Clinical Review by Code List PBCWA, Pg 765 Original policy |
| L7259 | Electronic wrist rotator, any type | Clinical Review by Code List PBCWA, Pg 765 Original policy |
| L8600 | Implantable breast prosthesis, silicone or equal | Clinical Review by Code List PBCWA, Pg 766 Original policy |
| L8614 | Cochlear device, includes all internal and external components | Clinical Review by Code List PBCWA, Pg 766 Original policy |
| L8619 | Cochlear implant external speech processor, replacement | Clinical Review by Code List PBCWA, Pg 766 Original policy |
| L8641 | Metatarsal joint implant | Clinical Review by Code List PBCWA, Pg 766 Original policy |
| L8642 | Hallux implant | Clinical Review by Code List PBCWA, Pg 766 Original policy |
| L8679 | Implantable neurostimulator, pulse generator, any type | Clinical Review by Code List PBCWA, Pg 766 Original policy |
| L8680 | Implantable neurostimulator electrode, each | Clinical Review by Code List PBCWA, Pg 766 Original policy |
| L8681 | Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 766 Original policy |