0964T prior authorization | Premera Blue Cross of Washington

0964T, Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; single arch, without mandibular advancement mechanism These criteria do not imply or guarantee approval., is on the Premera Blue Cross of Washington prior authorization list. Not a coverage or referral decision.

Code: 0964T
Description: Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; single arch, without mandibular advancement mechanism These criteria do not imply or guarantee approval.
Source: Clinical Review by Code List PBCWA, Pg 199 Original policy

Premera Blue Cross of Washington prior authorization

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