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Highmark Code List

Effective: 1/1/2021 CategoryCPT Code2 CPT Code DescriptionPrior Authorization Required3DI763763D Rendering W/O PostprocessingYes3DI763773D Rendering W PostprocessingYesBMRI77046 Magnetic resonance imaging, breast, without contrast material; unilateralYesBMRI77047 Magnetic resonance imaging, breast, without contrast material; bilateralYesBMRI77048 Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateralYesBMRI77049 Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateralYesCardiac Implantables33274 Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performedYesCardiac Implantables33275 Transcatheter removal of

Comprehensive Cardiology and Radiology Code List: Codes with asterisk(*) indicate new procedures requiring prior authorization through eviCore healthcare effective January 1, 2021: Effective: 1/1/2021 Category CPT® Code2: CPT ...

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