Premera Blue Cross of Washington prior authorization, page 8
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 |
|---|---|---|
| 15789 | Chemical peel, facial; dermal These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 235 Original policy |
| 15792 | Chemical peel, nonfacial; epidermal | Clinical Review by Code List PBCWA, Pg 236 Original policy |
| 15793 | Chemical peel, nonfacial; dermal | Clinical Review by Code List PBCWA, Pg 236 Original policy |
| 15820 | Blepharoplasty, lower eyelid | Clinical Review by Code List PBCWA, Pg 236 Original policy |
| 15821 | Blepharoplasty, lower eyelid; with extensive herniated fat pad | Clinical Review by Code List PBCWA, Pg 236 Original policy |
| 15822 | Blepharoplasty, upper eyelid | Clinical Review by Code List PBCWA, Pg 236 Original policy |
| 15823 | Blepharoplasty, upper eyelid; with excessive skin weighting down lid These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 236 Original policy |
| 15824 | Rhytidectomy; forehead | Clinical Review by Code List PBCWA, Pg 237 Original policy |
| 15825 | Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) | Clinical Review by Code List PBCWA, Pg 237 Original policy |
| 15826 | Rhytidectomy; glabellar frown lines | Clinical Review by Code List PBCWA, Pg 237 Original policy |
| 15828 | Rhytidectomy; cheek, chin, and neck | Clinical Review by Code List PBCWA, Pg 237 Original policy |
| 15829 | Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap | Clinical Review by Code List PBCWA, Pg 237 Original policy |
| 15830 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy | Clinical Review by Code List PBCWA, Pg 237 Original policy |
| 15832 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh | Clinical Review by Code List PBCWA, Pg 237 Original policy |
| 15833 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg | Clinical Review by Code List PBCWA, Pg 237 Original policy |
| 15834 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip | Clinical Review by Code List PBCWA, Pg 237 Original policy |
| 15835 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 237 Original policy |
| 15836 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm | Clinical Review by Code List PBCWA, Pg 238 Original policy |
| 15837 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand | Clinical Review by Code List PBCWA, Pg 238 Original policy |
| 15838 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad | Clinical Review by Code List PBCWA, Pg 238 Original policy |
| 15839 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area | Clinical Review by Code List PBCWA, Pg 238 Original policy |
| 15847 | Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 238 Original policy |
| 15876 | Suction assisted lipectomy; head and neck | Clinical Review by Code List PBCWA, Pg 238 Original policy |
| 15877 | Suction assisted lipectomy; trunk | Clinical Review by Code List PBCWA, Pg 238 Original policy |
| 15878 | Suction assisted lipectomy; upper extremity | Clinical Review by Code List PBCWA, Pg 238 Original policy |
| 15879 | Suction assisted lipectomy; lower extremity These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 238 Original policy |
| 17106 | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm | Clinical Review by Code List PBCWA, Pg 239 Original policy |
| 17107 | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm | Clinical Review by Code List PBCWA, Pg 239 Original policy |
| 17108 | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm | Clinical Review by Code List PBCWA, Pg 239 Original policy |
| 19296 | Placement of radiotherapy after loading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy | Clinical Review by Code List PBCWA, Pg 240 Original policy |
| 19297 | Placement of radiotherapy after loading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy | Clinical Review by Code List PBCWA, Pg 240 Original policy |
| 19298 | Placement of radiotherapy after loading brachytherapy catheters (multiple tube and balloon type) into the breast for interstitial radioelement application following (at time of or subsequent to) partial mastectomy, includes imaging guidance. | Clinical Review by Code List PBCWA, Pg 240 Original policy |
| 19300 | Mastectomy for gynecomastia | Clinical Review by Code List PBCWA, Pg 240 Original policy |
| 19303 | Mastectomy, simple, complete These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 240 Original policy |
| 19316 | Mastopexy | Clinical Review by Code List PBCWA, Pg 241 Original policy |
| 19318 | Breast reduction | Clinical Review by Code List PBCWA, Pg 241 Original policy |
| 19325 | Breast augmentation with implant | Clinical Review by Code List PBCWA, Pg 241 Original policy |
| 19328 | Removal of intact breast implant | Clinical Review by Code List PBCWA, Pg 241 Original policy |
| 19330 | Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel) | Clinical Review by Code List PBCWA, Pg 241 Original policy |
| 19340 | Insertion of breast implant on same day of mastectomy (ie, immediate) | Clinical Review by Code List PBCWA, Pg 241 Original policy |
| 19342 | Insertion or replacement of breast implant on separate day from mastectomy | Clinical Review by Code List PBCWA, Pg 241 Original policy |
| 19350 | Nipple/areola reconstruction These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 241 Original policy |
| 19355 | Correction of inverted nipples | Clinical Review by Code List PBCWA, Pg 242 Original policy |
| 19357 | Tissue expander placement in breast reconstruction, including subsequent expansion(s) | Clinical Review by Code List PBCWA, Pg 242 Original policy |
| 19370 | Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy | Clinical Review by Code List PBCWA, Pg 242 Original policy |
| 19371 | Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents | Clinical Review by Code List PBCWA, Pg 242 Original policy |
| 19380 | Revision of reconstructed breast (eg, significant removal of tissue, re- advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction) | Clinical Review by Code List PBCWA, Pg 242 Original policy |
| 20555 | Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure) | Clinical Review by Code List PBCWA, Pg 242 Original policy |
| 20974 | Electrical stimulation to aid bone healing; noninvasive (nonoperative) | Clinical Review by Code List PBCWA, Pg 243 Original policy |
| 20975 | Electrical stimulation to aid bone healing; invasive (operative) | Clinical Review by Code List PBCWA, Pg 243 Original policy |