Anthem Blue Cross and Blue Shield Nevada policy
CG-MED-98 Parenteral Antibiotics for the Treatment of Lyme Disease
CG-MED-98 Parenteral Antibiotics for the Treatment of Lyme Disease is a public Anthem Blue Cross and Blue Shield Nevada policy (policy CG-MED-98). It lists 33 CPT or HCPCS codes, 30 of them on the Anthem Blue Cross and Blue Shield Nevada prior authorization list. Not a coverage decision; the payer's own document governs.
- Policy number
- CG-MED-98
- 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 |
|---|---|---|---|
| 96365 | On the list | Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour | Policies naming 96365 |
| 96366 | Not listed | Policies naming 96366 | |
| 96367 | Not listed | Policies naming 96367 | |
| 96368 | Not listed | Policies naming 96368 | |
| 96372 | On the list | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular | Policies naming 96372 |
| J0456 | On the list | Azithromycin | Policies naming J0456 |
| J0558 | On the list | Injection, penicillin g benzathine and penicillin g procaine, 100,000 units | Policies naming J0558 |
| J0561 | On the list | Injection, penicillin g benzathine, 100,000 units | Policies naming J0561 |
| J0687 | On the list | Injection, cefazolin sodium (WG Critical Care), not therapeutically equivalent to J0690, 500 mg | Policies naming J0687 |
| J0688 | On the list | Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg | Policies naming J0688 |
| J0689 | On the list | Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg | Policies naming J0689 |
| J0690 | On the list | Cefazolin Sodium Injection | Policies naming J0690 |
| J0696 | On the list | Ceftriaxone Sodium Injection | Policies naming J0696 |
| J0698 | On the list | Cefotaxime Sodium Injection | Policies naming J0698 |
| J0743 | On the list | Cilastatin Sodium Injection | Policies naming J0743 |
| J0744 | On the list | Injection, ciprofloxacin for intravenous infusion, 200 mg | Policies naming J0744 |
| J1335 | On the list | Injection, ertapenem sodium, 500 mg | Policies naming J1335 |
| J1450 | On the list | Fluconazole | Policies naming J1450 |
| J1956 | On the list | Levofloxacin Injection | Policies naming J1956 |
| J2183 | On the list | Injection, meropenem (WG Critical Care), not therapeutically equivalent to J2185, 100 mg | Policies naming J2183 |
| J2184 | On the list | Injection, meropenem (B. Braun), not therapeutically equivalent to J2185, 100 mg | Policies naming J2184 |
| J2185 | On the list | Injection, meropenem, 100 mg | Policies naming J2185 |
| J2280 | On the list | Injection, moxifloxacin, 100 mg | Policies naming J2280 |
| J2281 | On the list | Injection, moxifloxacin (Fresenius Kabi), not therapeutically equivalent to J2280, 100 mg | Policies naming J2281 |
| J2510 | On the list | Penicillin G Procaine Inj | Policies naming J2510 |
| J2540 | On the list | Penicillin G Potassium Inj | Policies naming J2540 |
| S9494 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy (do not use with home infusion codes for hourly dosi | Policies naming S9494 |
| S9497 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every three hours | Policies naming S9497 |
| S9500 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours | Policies naming S9500 |
| S9501 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours | Policies naming S9501 |
| S9502 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours | Policies naming S9502 |
| S9503 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every six hours | Policies naming S9503 |
| S9504 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every four hours | Policies naming S9504 |
All Anthem Blue Cross and Blue Shield Nevada policies · Anthem Blue Cross and Blue Shield Nevada prior authorization CPT list