21147 prior authorization | Blue Cross and Blue Shield of Montana

21147, Reconstruction Midface Lefort I; 3 Or More Pieces Segment Movement In Any Direction Requiring Bone Grafts (Includes Obtaining Autografts) (Eg Ungrafted Bilateral Alveolar Cleft Or Multiple Osteotomies), is on the Blue Cross and Blue Shield of Montana commercial prior authorization list. Not a coverage or referral decision.

Code: 21147
Description: Reconstruction Midface Lefort I; 3 Or More Pieces Segment Movement In Any Direction Requiring Bone Grafts (Includes Obtaining Autografts) (Eg Ungrafted Bilateral Alveolar Cleft Or Multiple Osteotomies)
Source: 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 10 Original policy

Blue Cross and Blue Shield of Montana prior authorization

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