21155 prior authorization | Blue Cross and Blue Shield of Montana

21155, Reconstruction Midface Lefort Iii (Extracranial) Any Type Requiring Bone Grafts (Includes Obtaining Autografts); With Lefort I, is on the Blue Cross and Blue Shield of Montana commercial prior authorization list. Not a coverage or referral decision.

Code: 21155
Description: Reconstruction Midface Lefort Iii (Extracranial) Any Type Requiring Bone Grafts (Includes Obtaining Autografts); With Lefort I
Source: 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 11 Original policy

Blue Cross and Blue Shield of Montana prior authorization

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