Anthem Blue Cross and Blue Shield Nevada policy
CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
CG-MED-59 Upper Gastrointestinal Endoscopy in Adults is a public Anthem Blue Cross and Blue Shield Nevada policy (policy CG-MED-59). It lists 22 CPT or HCPCS codes, 22 of them on the Anthem Blue Cross and Blue Shield Nevada prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-MED-59
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross and Blue Shield Nevada prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield Nevada policies |
|---|---|---|---|
| 0652T | On the list | Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, includin | Policies naming 0652T |
| 0653T | On the list | Esophagogastroduodenoscopy, flexible, transnasal; with biopsy, single | Policies naming 0653T |
| 0654T | On the list | Esophagogastroduodenoscopy, flexible, transnasal; with insertion of in | Policies naming 0654T |
| 43233 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) | Policies naming 43233 |
| 43235 | On the list | Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | Policies naming 43235 |
| 43236 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance | Policies naming 43236 |
| 43239 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple | Policies naming 43239 |
| 43241 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with insertion of intraluminal tube or catheter | Policies naming 43241 |
| 43243 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric varices | Policies naming 43243 |
| 43244 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices | Policies naming 43244 |
| 43245 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie) | Policies naming 43245 |
| 43246 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube | Policies naming 43246 |
| 43247 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body | Policies naming 43247 |
| 43248 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire | Policies naming 43248 |
| 43249 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) | Policies naming 43249 |
| 43250 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery | Policies naming 43250 |
| 43251 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique | Policies naming 43251 |
| 43254 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection | Policies naming 43254 |
| 43255 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method | Policies naming 43255 |
| 43266 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) | Policies naming 43266 |
| 43270 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performe | Policies naming 43270 |
| C1726 | On the list | Catheter, balloon dilatation, nonvascular | Policies naming C1726 |
All Anthem Blue Cross and Blue Shield Nevada policies · Anthem Blue Cross and Blue Shield Nevada prior authorization CPT list