Premera Blue Cross of Washington prior authorization, page 43
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 |
|---|---|---|
| L8682 | Implantable neurostimulator radiofrequency receiver | Clinical Review by Code List PBCWA, Pg 767 Original policy |
| L8683 | Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver | Clinical Review by Code List PBCWA, Pg 767 Original policy |
| L8684 | Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement | Clinical Review by Code List PBCWA, Pg 767 Original policy |
| L8685 | Implantable neurostimulator pulse generator, single array, rechargeable, includes extension | Clinical Review by Code List PBCWA, Pg 767 Original policy |
| L8686 | Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 767 Original policy |
| L8687 | Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension | Clinical Review by Code List PBCWA, Pg 768 Original policy |
| L8688 | Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension | Clinical Review by Code List PBCWA, Pg 768 Original policy |
| L8689 | External recharging system for battery (internal) for use with implantable neurostimulator, replacement only | Clinical Review by Code List PBCWA, Pg 768 Original policy |
| L8690 | Auditory osseointegrated device, includes all internal and external components | Clinical Review by Code List PBCWA, Pg 768 Original policy |
| L8691 | Auditory osseointegrated device, external sound processor, replacement | Clinical Review by Code List PBCWA, Pg 768 Original policy |
| L8693 | Auditory osseointegrated device abutment, any length, replacement only | Clinical Review by Code List PBCWA, Pg 768 Original policy |
| L8694 | Auditory osseointegrated device, transducer/actuator, replacement only, each | Clinical Review by Code List PBCWA, Pg 768 Original policy |
| Q0138 | Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 770 Original policy |
| Q0139 | Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD on dialysis) | Clinical Review by Code List PBCWA, Pg 771 Original policy |
| Q2041 | Axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Clinical Review by Code List PBCWA, Pg 772 Original policy |
| Q2042 | Tisagenlecleucel, up to 600 million car- positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Clinical Review by Code List PBCWA, Pg 772 Original policy |
| Q2043 | Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap- gm-csf, including leukapheresis and all other preparatory procedures, per infusion | Clinical Review by Code List PBCWA, Pg 772 Original policy |
| Q2050 | Injection, doxorubicin HCl, liposomal, not otherwise specified, 10 mg | Clinical Review by Code List PBCWA, Pg 772 Original policy |
| Q2053 | Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Clinical Review by Code List PBCWA, Pg 772 Original policy |
| Q2054 | Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 772 Original policy |
| Q2055 | Idecabtagene vicleucel, up to 460 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Clinical Review by Code List PBCWA, Pg 773 Original policy |
| Q2056 | Ciltacabtagene autoleucel, up to 100 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Clinical Review by Code List PBCWA, Pg 773 Original policy |
| Q2057 | Afamitresgene autoleucel, including leukapheresis and dose preparation procedures, per therapeutic dose | Clinical Review by Code List PBCWA, Pg 773 Original policy |
| Q2058 | Obecabtagene autoleucel, 10 up to 400 million CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per infusion | Clinical Review by Code List PBCWA, Pg 773 Original policy |
| Q3001 | Radioelements for brachytherapy, any type, each | Clinical Review by Code List PBCWA, Pg 773 Original policy |
| Q3027 | Injection, interferon beta-1a, 1 mcg for intramuscular use | Clinical Review by Code List PBCWA, Pg 773 Original policy |
| Q3028 | Injection, interferon beta-1a, 1 mcg for subcutaneous use These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 773 Original policy |
| Q4081 | Injection, epoetin alfa, 100 units (for ESRD on dialysis) | Clinical Review by Code List PBCWA, Pg 774 Original policy |
| Q4132 | Grafix Core and GrafixPL Core, per square centimeter (add-on, list separately in addition to primary procedure) | Clinical Review by Code List PBCWA, Pg 776 Original policy |
| Q4133 | Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per square centimeter (add-on, list separately in addition to primary procedure) | Clinical Review by Code List PBCWA, Pg 776 Original policy |
| Q4151 | AmnioBand or Guardian, per square centimeter (add-on, list separately in addition to primary procedure) | Clinical Review by Code List PBCWA, Pg 777 Original policy |
| Q4154 | Biovance, per square centimeter (add-on, list separately in addition to primary procedure) | Clinical Review by Code List PBCWA, Pg 778 Original policy |
| Q4159 | Affinity, per square centimeter (add-on, list separately in addition to primary procedure) | Clinical Review by Code List PBCWA, Pg 778 Original policy |
| Q4186 | Epifix, per square centimeter (add-on, list separately in addition to primary procedure) | Clinical Review by Code List PBCWA, Pg 780 Original policy |
| Q4187 | EpiCord, per square centimeter (add-on, list separately in addition to primary procedure) | Clinical Review by Code List PBCWA, Pg 780 Original policy |
| Q4285 | Nudyn DL or Nudyn DL Mesh, per square centimeter (add-on, list separately in addition to primary procedure) | Clinical Review by Code List PBCWA, Pg 789 Original policy |
| Q4286 | Nudyn SL or Nudyn SLW, per square centimeter (add-on, list separately in addition to primary procedure) | Clinical Review by Code List PBCWA, Pg 789 Original policy |
| Q5098 | Injection, ustekinumab-srlf (Imuldosa), biosimilar, 1 mg | Clinical Review by Code List PBCWA, Pg 805 Original policy |
| Q5099 | Injection, ustekinumab-stba (Steqeyma), biosimilar, 1 mg | Clinical Review by Code List PBCWA, Pg 805 Original policy |
| Q5100 | Injection, ustekinumab-kfce (Yesintek), biosimilar, 1 mg | Clinical Review by Code List PBCWA, Pg 805 Original policy |
| Q5101 | Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram | Clinical Review by Code List PBCWA, Pg 805 Original policy |
| Q5103 | Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg | Clinical Review by Code List PBCWA, Pg 805 Original policy |
| Q5104 | Injection, infliximab-abda, biosimilar, (renflexis), 10 mg | Clinical Review by Code List PBCWA, Pg 805 Original policy |
| Q5105 | Injection, Epoetin Alfa-EPBX, Biosimilar, (Retacrit) (for ESRD on dialysis), 100 units | Clinical Review by Code List PBCWA, Pg 805 Original policy |
| Q5106 | Injection, Epoetin Alfa-EPBX, Biosimilar, (Retacrit) (for non-ESRD use), 1000 units | Clinical Review by Code List PBCWA, Pg 805 Original policy |
| Q5107 | Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 805 Original policy |
| Q5108 | Injection, pegfilgrastim-jmdb (fulphila), biosimilar,0.5 mg | Clinical Review by Code List PBCWA, Pg 806 Original policy |
| Q5111 | Injection, pegfilgrastim-cbqv (Udenyca), biosimilar, 0.5 mg | Clinical Review by Code List PBCWA, Pg 806 Original policy |
| Q5112 | Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg | Clinical Review by Code List PBCWA, Pg 806 Original policy |
| Q5113 | Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg | Clinical Review by Code List PBCWA, Pg 806 Original policy |