Anthem Blue Cross and Blue Shield Nevada policy
Medicare Advantage Precertification Requirements – 2019
Medicare Advantage Precertification Requirements – 2019 is a public Anthem Blue Cross and Blue Shield Nevada policy. It lists 191 CPT or HCPCS codes, 134 of them on the Anthem Blue Cross and Blue Shield Nevada prior authorization list. Not a coverage decision; the payer's own document governs.
View the original policy (PDF) ↗
- States
- CA, CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, VA, WI
- 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 |
|---|---|---|---|
| 79403 | On the list | Radiopharmaceutical Therapy, Radiolabeled Monoclonal Antibody By Intravenous Infusion | Policies naming 79403 |
| A9543 | On the list | Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries | Policies naming A9543 |
| A9606 | On the list | Radium RA-223 dichloride, therapeutic, per UCI | Policies naming A9606 |
| A9699 | Not listed | Policies naming A9699 | |
| C9014 | Not listed | Policies naming C9014 | |
| C9016 | Not listed | Policies naming C9016 | |
| C9024 | Not listed | Policies naming C9024 | |
| C9028 | Not listed | Policies naming C9028 | |
| C9029 | Not listed | Policies naming C9029 | |
| C9030 | Not listed | Policies naming C9030 | |
| C9031 | Not listed | Policies naming C9031 | |
| C9032 | Not listed | Policies naming C9032 | |
| C9257 | On the list | Injection, bevacizumab, 0.25 mg | Policies naming C9257 |
| C9399 | Not listed | Policies naming C9399 | |
| C9463 | Not listed | Policies naming C9463 | |
| C9464 | Not listed | Policies naming C9464 | |
| C9465 | Not listed | Policies naming C9465 | |
| C9466 | Not listed | Policies naming C9466 | |
| C9467 | Not listed | Policies naming C9467 | |
| C9468 | Not listed | Policies naming C9468 | |
| C9492 | Not listed | Policies naming C9492 | |
| J0129 | On the list | Injection, abatacept, 10 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) | Policies naming J0129 |
| J0135 | On the list | Adalimumab injection | Policies naming J0135 |
| J0178 | On the list | Injection, aflibercept, 1 mg | Policies naming J0178 |
| J0202 | On the list | Injection, alemtuzumab, 1 mg | Policies naming J0202 |
| J0485 | On the list | Injection, belatacept, 1 mg | Policies naming J0485 |
| J0490 | On the list | Injection, belimumab, 10 mg | Policies naming J0490 |
| J0585 | On the list | Injection, Onabotulinumtoxina, 1 Unit | Policies naming J0585 |
| J0586 | On the list | Injection, Abobotulinumtoxina, 5 Units | Policies naming J0586 |
| J0587 | On the list | Injection, Rimabotulinumtoxinb, 100 Units | Policies naming J0587 |
| J0588 | On the list | Injection, incobotulinumtoxinA, 1 unit | Policies naming J0588 |
| J0596 | On the list | Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units | Policies naming J0596 |
| J0881 | On the list | Injection, darbepoetin alfa, 1 mcg (non-ESRD use) | Policies naming J0881 |
| J0885 | On the list | Injection, epoetin alfa, (for non-ESRD use), 1000 units | Policies naming J0885 |
| J0888 | On the list | Injectin, epoetin beta, 1 microgram, (for non esrd use) | Policies naming J0888 |
| J0897 | On the list | Injection, denosumab, 1 mg | Policies naming J0897 |
| J1300 | On the list | Injection, eculizumab, 10 mg | Policies naming J1300 |
| J1325 | On the list | Epoprostenol Injection | Policies naming J1325 |
| J1428 | On the list | Injection, eteplirsen, 10 mg | Policies naming J1428 |
| J1438 | On the list | Etanercept Injection | Policies naming J1438 |
| J1442 | On the list | 5G-CSFexcludes biosimilars, 1 microgram | Policies naming J1442 |
| J1447 | On the list | Injection, tbo-filgrastim, 1 microgram | Policies naming J1447 |
| J1453 | Not listed | Policies naming J1453 | |
| J1459 | On the list | Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg | Policies naming J1459 |
| J1555 | On the list | Injection, immune globulin (Cuvitru), 100 mg | Policies naming J1555 |
| J1556 | On the list | Injection, immune globulin (bivigam), 500 mg | Policies naming J1556 |
| J1557 | On the list | Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg | Policies naming J1557 |
| J1559 | On the list | Injection, immune globulin (hizentra), 100 mg | Policies naming J1559 |
| J1561 | On the list | Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg | Policies naming J1561 |
| J1562 | Not listed | Policies naming J1562 | |
| J1566 | On the list | Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg | Policies naming J1566 |
| J1568 | On the list | Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. | Policies naming J1568 |
| J1569 | On the list | Injection, immune globulin, (gammagard liquid/gammagard liquid erc), 500 mg | Policies naming J1569 |
| J1572 | On the list | Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg | Policies naming J1572 |
| J1575 | On the list | Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin | Policies naming J1575 |
| J1599 | On the list | Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg | Policies naming J1599 |
| J1602 | On the list | Injection, golimumab, 1 mg, for intravenous use | Policies naming J1602 |
| J1627 | Not listed | Policies naming J1627 | |
| J1740 | Not listed | Policies naming J1740 | |
| J1745 | On the list | Injection, infliximab, excludes biosimilar, 10 mg | Policies naming J1745 |
| J1950 | On the list | Leuprolide Acetate /3.75 Mg | Policies naming J1950 |
| J2182 | On the list | Injection, mepolizumab, 1 mg | Policies naming J2182 |
| J2278 | On the list | Injection, ziconotide, 1 mcg | Policies naming J2278 |
| J2323 | On the list | Imjection, natalizumab, 1 mg | Policies naming J2323 |
| J2326 | On the list | Injection, nusinersen, 0.1 mg | Policies naming J2326 |
| J2350 | On the list | Injection, ocrelizumab, 1 mg | Policies naming J2350 |
| J2353 | On the list | Injection, octreotide, depot form for intramuscular injection, 1 mg | Policies naming J2353 |
| J2354 | On the list | Injection, octreotide, non-depot form for subcutaneous or intravenous | Policies naming J2354 |
| J2355 | Not listed | Policies naming J2355 | |
| J2357 | On the list | Omalizumab injection | Policies naming J2357 |
| J2469 | Not listed | Policies naming J2469 | |
| J2503 | Not listed | Policies naming J2503 | |
| J2505 | On the list | Injection, pegfilgrastim, 6 mg | Policies naming J2505 |
| J2507 | On the list | Injection, pegloticase, 1 mg | Policies naming J2507 |
| J2778 | On the list | Injection, ranibizumab, 0.1 mg | Policies naming J2778 |
| J2786 | On the list | Injection, reslizumab, 1 mg | Policies naming J2786 |
| J2796 | On the list | Injection, Romiplostim, 10 Micrograms | Policies naming J2796 |
| J2820 | On the list | Sargramostim Injection | Policies naming J2820 |
| J2860 | Not listed | Policies naming J2860 | |
| J2941 | On the list | Injection, somatropin, 1 mg | Policies naming J2941 |
| J3262 | On the list | Injection, tocilizumab, 1 mg | Policies naming J3262 |
| J3285 | On the list | Injection, treprostinil, 1 mg | Policies naming J3285 |
| J3315 | Not listed | Policies naming J3315 | |
| J3358 | On the list | Ustekinumab, for intravenous injection, 1 mg | Policies naming J3358 |
| J3380 | On the list | Injection, vedolizumab, IV, 1 mg | Policies naming J3380 |
| J3489 | On the list | Injection, zoledronic acid, 1 mg | Policies naming J3489 |
| J3490 | Not listed | Policies naming J3490 | |
| J3590 | Not listed | Policies naming J3590 | |
| J7175 | On the list | Injection, factor x, (human), 1 i.u. | Policies naming J7175 |
| J7178 | On the list | Injection, human fibrinogen concentrate, not otherwise specified, 1 mg | Policies naming J7178 |
| J7179 | On the list | Injection, von willebrand factor (recombinant), (vonvendi), 1 i.u. vwf:rco | Policies naming J7179 |
| J7180 | On the list | Injection, factor XIII (antihemophilic factor, human), 1 IU | Policies naming J7180 |
| J7181 | On the list | Injection, factor xiii a-subunit, (recombinant), per iu | Policies naming J7181 |
| J7182 | On the list | Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu | Policies naming J7182 |
| J7183 | On the list | Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo | Policies naming J7183 |
| J7185 | On the list | Injection, Factor Viii (Antihemophilic Factor, Recombinant) (Xyntha), Per I.U. | Policies naming J7185 |
| J7186 | On the list | Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per factor VIII i.u. | Policies naming J7186 |
| J7187 | On the list | Injection, von Willebrand factor complex (Humate-P), per IU vWF-RC0 | Policies naming J7187 |
| J7188 | On the list | Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. | Policies naming J7188 |
| J7189 | On the list | Factor VIIa (antihemophilic Factor, recombinant), per 1 mcg | Policies naming J7189 |
| J7190 | On the list | Factor Viii | Policies naming J7190 |
| J7191 | On the list | Factor Viii (Porcine) | Policies naming J7191 |
| J7192 | On the list | Factor Viii (Antihemophilic Factor, Recombinant) Per I.U., Not Otherwise Specified | Policies naming J7192 |
| J7193 | On the list | Factor IX (antihemophilic factor, purified, non-recombinant) per IU | Policies naming J7193 |
| J7194 | On the list | Factor Ix Complex | Policies naming J7194 |
| J7195 | On the list | Factor IX (antihemophilic factor, recombinant) per IU | Policies naming J7195 |
| J7198 | On the list | Anti-Inhibitor | Policies naming J7198 |
| J7199 | Not listed | Policies naming J7199 | |
| J7200 | On the list | Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu | Policies naming J7200 |
| J7201 | On the list | Injection, factor IX, Fc fusion protein, (recombinant), Alprolix, 1 IU | Policies naming J7201 |
| J7202 | On the list | Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. | Policies naming J7202 |
| J7205 | On the list | Injection, factor viii fc fusion (recombinant), per iu | Policies naming J7205 |
| J7207 | On the list | Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. | Policies naming J7207 |
| J7209 | On the list | Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u. | Policies naming J7209 |
| J7210 | On the list | Injection, Factor VIII, (antihemophilic factor, recombinant), (Afstyla), 1 IU | Policies naming J7210 |
| J7211 | On the list | Injection, Factor VIII, (antihemophilic factor, recombinant), (Kovaltry), 1 IU | Policies naming J7211 |
| J7311 | On the list | Injection, fluocinolone acetonide, intravitreal implant (Retisert), 0.01 mg | Policies naming J7311 |
| J7312 | On the list | Injection, dexamethasone, intravitreal implant, 0.1 mg | Policies naming J7312 |
| J7313 | On the list | Injection, fluocinolone acetonide, intravitreal implant (Iluvien), 0.01 mg | Policies naming J7313 |
| J7316 | Not listed | Policies naming J7316 | |
| J7320 | Not listed | Policies naming J7320 | |
| J7321 | Not listed | Policies naming J7321 | |
| J7322 | Not listed | Policies naming J7322 | |
| J7323 | Not listed | Policies naming J7323 | |
| J7324 | Not listed | Policies naming J7324 | |
| J7325 | Not listed | Policies naming J7325 | |
| J7326 | Not listed | Policies naming J7326 | |
| J7327 | Not listed | Policies naming J7327 | |
| J7328 | Not listed | Policies naming J7328 | |
| J7340 | On the list | Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml | Policies naming J7340 |
| J7686 | On the list | Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, 1.74 mg | Policies naming J7686 |
| J9010 | Not listed | Policies naming J9010 | |
| J9015 | On the list | Injection, aldesleukin, per single use vial | Policies naming J9015 |
| J9022 | On the list | Injection, atezolizumab, 10 mg | Policies naming J9022 |
| J9023 | On the list | Injection, avelumab, 10 mg | Policies naming J9023 |
| J9025 | Not listed | Policies naming J9025 | |
| J9034 | On the list | Injection, bendamustine hcl (bendeka), 1 mg | Policies naming J9034 |
| J9035 | On the list | Bevacizumab injection | Policies naming J9035 |
| J9039 | On the list | Injection, blinatumomab, 1 microgram | Policies naming J9039 |
| J9042 | On the list | Injection, brentuximab vedotin, 1 mg | Policies naming J9042 |
| J9043 | On the list | Injection, cabazitaxel, 1 mg | Policies naming J9043 |
| J9047 | On the list | Injection, carfilzomib, 1 mg | Policies naming J9047 |
| J9055 | On the list | Cetuximab injection | Policies naming J9055 |
| J9145 | On the list | Injection, daratumumab, 10 mg | Policies naming J9145 |
| J9155 | Not listed | Policies naming J9155 | |
| J9176 | On the list | Injection, elotuzumab, 1 mg | Policies naming J9176 |
| J9179 | On the list | Injection, eribulin mesylate, 0.1 mg | Policies naming J9179 |
| J9202 | On the list | Goserelin Acetate Implant | Policies naming J9202 |
| J9203 | On the list | Injection, gemtuzumab ozogamicin, 0.1 mg | Policies naming J9203 |
| J9207 | On the list | Injection, ixabepilone, 1 mg | Policies naming J9207 |
| J9217 | On the list | Leuprolide Acetate Suspnsion | Policies naming J9217 |
| J9218 | Not listed | Policies naming J9218 | |
| J9219 | Not listed | Policies naming J9219 | |
| J9226 | On the list | Histrelin implant (supprelin LA), 50 mg | Policies naming J9226 |
| J9228 | On the list | Injection, ipilimumab, 1 mg | Policies naming J9228 |
| J9262 | On the list | Injection, omacetaxine mepesuccinate, 0.01 mg | Policies naming J9262 |
| J9264 | On the list | Injection, paclitaxel protein-bound particles, 1 mg | Policies naming J9264 |
| J9266 | On the list | Injection, pegaspargase, per single dose vial | Policies naming J9266 |
| J9271 | On the list | Injection, pembrolizumab, 1 mg | Policies naming J9271 |
| J9285 | Not listed | Policies naming J9285 | |
| J9295 | Not listed | Policies naming J9295 | |
| J9299 | On the list | Injection, nivolumab, 1 mg | Policies naming J9299 |
| J9301 | On the list | Injection, obinutuzumab, 10 mg | Policies naming J9301 |
| J9302 | On the list | Injection, ofatumumab, 10 mg | Policies naming J9302 |
| J9303 | On the list | Injection, panitumumab, 10 mg | Policies naming J9303 |
| J9305 | On the list | Injection, pemetrexed, NOS,10 mg | Policies naming J9305 |
| J9306 | On the list | Injection, pertuzumab, 1 mg | Policies naming J9306 |
| J9308 | On the list | Injection, ramucirumab, 5 mg | Policies naming J9308 |
| J9310 | Not listed | Policies naming J9310 | |
| J9315 | Not listed | Policies naming J9315 | |
| J9325 | On the list | Injection, talimogene laherparepvec, per 1 million plaque forming units | Policies naming J9325 |
| J9351 | Not listed | Policies naming J9351 | |
| J9352 | Not listed | Policies naming J9352 | |
| J9354 | On the list | Injection, ado-trastuzumab emtansine, 1 mg | Policies naming J9354 |
| J9355 | Not listed | Policies naming J9355 | |
| J9400 | On the list | Injection, ziv-aflibercept, 1 mg | Policies naming J9400 |
| J9999 | Not listed | Policies naming J9999 | |
| Q0515 | Not listed | Policies naming Q0515 | |
| Q2041 | On the list | Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Policies naming Q2041 |
| Q2043 | On the list | Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap- gm-csf, including leukapheresis and all other preparatory procedures, per infusion | Policies naming Q2043 |
| Q2049 | Not listed | Policies naming Q2049 | |
| Q2050 | Not listed | Policies naming Q2050 | |
| Q4074 | On the list | Iloprost, Inhalation Solution, Fda-Approved Final Product, Non-Compounded, Administered Through Dme, Unit Dose Form, Up | Policies naming Q4074 |
| Q5101 | On the list | Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram | Policies naming Q5101 |
| Q5103 | On the list | Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg | Policies naming Q5103 |
| Q5104 | On the list | Injection, infliximab-abda, biosimilar, (renflexis), 10 mg | Policies naming Q5104 |
| Q5106 | On the list | Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for non-ESRD use), 1000 units | Policies naming Q5106 |
| Q5108 | On the list | Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg | Policies naming Q5108 |
| Q5110 | On the list | Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram | Policies naming Q5110 |
| Q9993 | Not listed | Policies naming Q9993 | |
| Q9995 | Not listed | Policies naming Q9995 |
All Anthem Blue Cross and Blue Shield Nevada policies · Anthem Blue Cross and Blue Shield Nevada prior authorization CPT list