Premera Blue Cross of Washington prior authorization, page 46

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
Code	Description	Source
S8092	Electron beam computed tomography (also known as ultrafast CT, cine CT)	Clinical Review by Code List PBCWA, Pg 821 Original policy
S9123	Nursing care, in the home; by registered nurse, per hour	Clinical Review by Code List PBCWA, Pg 822 Original policy
S9124	Nursing care, in the home; by licensed practical nurse, per hour	Clinical Review by Code List PBCWA, Pg 822 Original policy
S9433	Medical food nutritionally complete, administered orally, providing 100% of nutritional intake These criteria do not imply or guarantee approval.	Clinical Review by Code List PBCWA, Pg 822 Original policy
S9960	Ambulance service, conventional air services, nonemergency transport, one way (fixed wing)	Clinical Review by Code List PBCWA, Pg 824 Original policy
S9961	Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)	Clinical Review by Code List PBCWA, Pg 824 Original policy
S9988	Services provided as part of a phase I clinical trial	Clinical Review by Code List PBCWA, Pg 824 Original policy
S9990	Services provided as part of a Phase II clinical trial	Clinical Review by Code List PBCWA, Pg 824 Original policy
S9991	Services provided as part of a phase III clinical trial These criteria do not imply or guarantee approval.	Clinical Review by Code List PBCWA, Pg 824 Original policy
T2036	Therapeutic camping, overnight, waiver; each session	Clinical Review by Code List PBCWA, Pg 829 Original policy
T2037	Therapeutic camping, day, waiver; each session	Clinical Review by Code List PBCWA, Pg 829 Original policy
T2048	Behavioral health; long-term care residential (nonacute care in a residential treatment program where stay is typically longer than 30 days), with room and board, per diem	Clinical Review by Code List PBCWA, Pg 830 Original policy
V2629	Prosthetic eye, other type	Clinical Review by Code List PBCWA, Pg 832 Original policy

Sources

Clinical Review by Code List PBCWA

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.

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