77768 prior authorization | Premera Blue Cross of Washington

77768, Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions 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: 77768
Description: Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions These criteria do not imply or guarantee approval.
Source: Clinical Review by Code List PBCWA, Pg 427 Original policy

Premera Blue Cross of Washington prior authorization

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