Premera Blue Cross of Washington prior authorization, page 45
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 |
|---|---|---|
| Q5168 | Injection, ranibizumab-leyk (Nufymco), biosimilar, 0.1 mg These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 810 Original policy |
| Q5169 | Injection, pegfilgrastim-unne (Armlupeg), biosimilar, 0.5 mg | Clinical Review by Code List PBCWA, Pg 811 Original policy |
| Q5170 | Injection, aflibercept-boav (Eydenzelt), biosimilar, 1 mg | Clinical Review by Code List PBCWA, Pg 811 Original policy |
| Q5171 | Injection, denosumab-mobz (Boncresa), biosimilar, 1 mg | Clinical Review by Code List PBCWA, Pg 811 Original policy |
| Q5172 | Injection, filgrastim-laha (Filkri), biosimilar, 1 microgram | Clinical Review by Code List PBCWA, Pg 811 Original policy |
| Q5173 | Injection, denosumab-adet (Ponlimsi), biosimilar, 1 mg | Clinical Review by Code List PBCWA, Pg 811 Original policy |
| Q9996 | Injection, ustekinumab-ttwe (Pyzchiva), subcutaneous, 1 mg | Clinical Review by Code List PBCWA, Pg 811 Original policy |
| Q9997 | Injection, ustekinumab-ttwe (Pyzchiva), intravenous, 1 mg | Clinical Review by Code List PBCWA, Pg 811 Original policy |
| Q9998 | Injection, ustekinumab-aekn (Selarsdi), 1 mg | Clinical Review by Code List PBCWA, Pg 811 Original policy |
| Q9999 | Injection, ustekinumab-aauz (Otulfi), biosimilar, 1 mg | Clinical Review by Code List PBCWA, Pg 811 Original policy |
| S0128 | Injection, follitropin beta, 75 IU | Clinical Review by Code List PBCWA, Pg 811 Original policy |
| S0132 | Injection, ganirelix acetate, 250 mcg | Clinical Review by Code List PBCWA, Pg 811 Original policy |
| S0145 | Injection, pegylated interferon alfa-2a, 180 mcg per ml These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 811 Original policy |
| S1034 | Artificial pancreas device system (e.g., low glucose suspend [LGS] feature) including continuous glucose monitor | Clinical Review by Code List PBCWA, Pg 813 Original policy |
| S1035 | Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device system | Clinical Review by Code List PBCWA, Pg 813 Original policy |
| S1036 | Transmitter; external, for use with artificial pancreas device system | Clinical Review by Code List PBCWA, Pg 813 Original policy |
| S1037 | Receiver (monitor); external, for use with artificial pancreas device system | Clinical Review by Code List PBCWA, Pg 813 Original policy |
| S1040 | Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) | Clinical Review by Code List PBCWA, Pg 813 Original policy |
| S2053 | Transplantation of small intestine and liver allografts | Clinical Review by Code List PBCWA, Pg 813 Original policy |
| S2054 | Transplantation of multivisceral organs | Clinical Review by Code List PBCWA, Pg 813 Original policy |
| S2060 | Lobar lung transplantation | Clinical Review by Code List PBCWA, Pg 813 Original policy |
| S2065 | Simultaneous pancreas kidney transplantation | Clinical Review by Code List PBCWA, Pg 813 Original policy |
| S2080 | Laser-assisted uvulopalatoplasty (LAUP) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 813 Original policy |
| S2095 | Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres | Clinical Review by Code List PBCWA, Pg 814 Original policy |
| S2102 | Islet cell tissue transplant from pancreas; allogeneic | Clinical Review by Code List PBCWA, Pg 814 Original policy |
| S2107 | Adoptive immunotherapy i.e. development of specific antitumor reactivity (e.g., tumor- infiltrating lymphocyte therapy) per course of treatment | Clinical Review by Code List PBCWA, Pg 814 Original policy |
| S2112 | Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells) | Clinical Review by Code List PBCWA, Pg 814 Original policy |
| S2142 | Cord blood-derived stem-cell transplantation, allogeneic | Clinical Review by Code List PBCWA, Pg 814 Original policy |
| S2150 | Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications including pheresis and cell preparation/storage; marrow ablative therapy; drugs, supplies, hospitalization These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 814 Original policy |
| S2152 | Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor (s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up | Clinical Review by Code List PBCWA, Pg 815 Original policy |
| S2235 | implantation of auditory brain stem implant | Clinical Review by Code List PBCWA, Pg 815 Original policy |
| S2340 | Chemodenervation of abductor muscle(s) of vocal cord | Clinical Review by Code List PBCWA, Pg 815 Original policy |
| S2341 | Chemodenervation of adductor muscle(s) of vocal cord | Clinical Review by Code List PBCWA, Pg 815 Original policy |
| S3800 | Genetic testing for amyotrophic lateral sclerosis (ALS) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 815 Original policy |
| S3840 | DNA analysis for germline mutations of the RET proto-oncogene for susceptibility to multiple endocrine neoplasia type 2 | Clinical Review by Code List PBCWA, Pg 816 Original policy |
| S3841 | Genetic testing for retinoblastoma | Clinical Review by Code List PBCWA, Pg 816 Original policy |
| S3842 | Genetic testing for von Hippel-Lindeau disease | Clinical Review by Code List PBCWA, Pg 816 Original policy |
| S3844 | DNA analysis of the connection 26 gene (GJB2) for susceptibility to congenital, profound deafness DNA analysis deafness | Clinical Review by Code List PBCWA, Pg 816 Original policy |
| S3845 | Genetic testing for alpha-thalassemia These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 816 Original policy |
| S3846 | Genetic testing for hemoglobin E beta- thalassemia | Clinical Review by Code List PBCWA, Pg 817 Original policy |
| S3849 | Genetic testing for Niemann-Pick disease | Clinical Review by Code List PBCWA, Pg 817 Original policy |
| S3850 | Genetic testing for sickle cell anemia | Clinical Review by Code List PBCWA, Pg 817 Original policy |
| S3852 | DNA analysis for APOE essilon 4 allele for susceptibility to Alzheimer's disease | Clinical Review by Code List PBCWA, Pg 817 Original policy |
| S3853 | Genetic testing for myotonic muscular dystrophy These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 817 Original policy |
| S3854 | Gene expression profiling panel for use in the management of breast cancer treatment | Clinical Review by Code List PBCWA, Pg 818 Original policy |
| S3861 | Genetic testing, sodium channel, voltage- gated, type V, alpha subunit (SCN5A) and variants for suspected Brugada Syndrome | Clinical Review by Code List PBCWA, Pg 818 Original policy |
| S3865 | Comprehensive gene sequence analysis for hypertrophic cardiomyopathy | Clinical Review by Code List PBCWA, Pg 818 Original policy |
| S3866 | Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family | Clinical Review by Code List PBCWA, Pg 818 Original policy |
| S3870 | Comparative genomic hybrization (CGH) microarray testing for developmental delay, autism spectrum disorder and/or mental retardation | Clinical Review by Code List PBCWA, Pg 818 Original policy |
| S8030 | Scleral application of tantalum ring(s) for localization of lesions for proton beam therapy | Clinical Review by Code List PBCWA, Pg 821 Original policy |