Premera Blue Cross of Washington prior authorization, page 9
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 |
|---|---|---|
| 20979 | Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) | Clinical Review by Code List PBCWA, Pg 243 Original policy |
| 20982 | Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 243 Original policy |
| 20983 | Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation | Clinical Review by Code List PBCWA, Pg 244 Original policy |
| 21010 | Arthrotomy, temporomandibular joint | Clinical Review by Code List PBCWA, Pg 244 Original policy |
| 21050 | Condylectomy, temporomandibular joint (separate procedure) | Clinical Review by Code List PBCWA, Pg 244 Original policy |
| 21060 | Meniscectomy, partial or complete, temporomandibular joint (separate procedure) | Clinical Review by Code List PBCWA, Pg 244 Original policy |
| 21085 | Impression and custom preparation; oral surgical splint | Clinical Review by Code List PBCWA, Pg 245 Original policy |
| 21087 | Impression and custom preparation; nasal prosthesis | Clinical Review by Code List PBCWA, Pg 245 Original policy |
| 21137 | Reduction forehead; contouring only | Clinical Review by Code List PBCWA, Pg 246 Original policy |
| 21138 | Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 246 Original policy |
| 21139 | Reduction forehead; contouring and setback of anterior frontal sinus wall | Clinical Review by Code List PBCWA, Pg 247 Original policy |
| 21141 | Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft | Clinical Review by Code List PBCWA, Pg 247 Original policy |
| 21188 | Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) | Clinical Review by Code List PBCWA, Pg 249 Original policy |
| 21210 | Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) | Clinical Review by Code List PBCWA, Pg 251 Original policy |
| 21280 | Medial canthopexy (separate procedure) | Clinical Review by Code List PBCWA, Pg 252 Original policy |
| 21282 | Lateral canthopexy | Clinical Review by Code List PBCWA, Pg 252 Original policy |
| 21295 | Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach | Clinical Review by Code List PBCWA, Pg 252 Original policy |
| 21296 | Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach | Clinical Review by Code List PBCWA, Pg 252 Original policy |
| 21615 | Excision first and/or cervical rib | Clinical Review by Code List PBCWA, Pg 253 Original policy |
| 21685 | Hyoid myotomy and suspension | Clinical Review by Code List PBCWA, Pg 253 Original policy |
| 21811 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1- 3 ribs | Clinical Review by Code List PBCWA, Pg 253 Original policy |
| 22510 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 253 Original policy |
| 22511 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral | Clinical Review by Code List PBCWA, Pg 254 Original policy |
| 22512 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure | Clinical Review by Code List PBCWA, Pg 254 Original policy |
| 22513 | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic | Clinical Review by Code List PBCWA, Pg 254 Original policy |
| 22514 | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 254 Original policy |
| 22515 | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure | Clinical Review by Code List PBCWA, Pg 255 Original policy |
| 22533 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 255 Original policy |
| 22534 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 256 Original policy |
| 22551 | Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 | Clinical Review by Code List PBCWA, Pg 256 Original policy |
| 22552 | Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure) | Clinical Review by Code List PBCWA, Pg 256 Original policy |
| 22554 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 256 Original policy |
| 22558 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | Clinical Review by Code List PBCWA, Pg 257 Original policy |
| 22585 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 257 Original policy |
| 22586 | Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace | Clinical Review by Code List PBCWA, Pg 257 Original policy |
| 22600 | Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 257 Original policy |
| 22612 | Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique) | Clinical Review by Code List PBCWA, Pg 258 Original policy |
| 22614 | Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 258 Original policy |
| 22630 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar | Clinical Review by Code List PBCWA, Pg 258 Original policy |
| 22632 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 258 Original policy |
| 22633 | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar | Clinical Review by Code List PBCWA, Pg 259 Original policy |
| 22634 | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional | Clinical Review by Code List PBCWA, Pg 259 Original policy |
| 22800 | Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments | Clinical Review by Code List PBCWA, Pg 259 Original policy |
| 22802 | Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments | Clinical Review by Code List PBCWA, Pg 259 Original policy |
| 22804 | Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments | Clinical Review by Code List PBCWA, Pg 259 Original policy |
| 22808 | Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 259 Original policy |
| 22810 | Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments | Clinical Review by Code List PBCWA, Pg 260 Original policy |
| 22812 | Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments | Clinical Review by Code List PBCWA, Pg 260 Original policy |
| 22856 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical | Clinical Review by Code List PBCWA, Pg 260 Original policy |
| 22857 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); single interspace, lumbar | Clinical Review by Code List PBCWA, Pg 260 Original policy |