Anthem Blue Cross and Blue Shield Nevada policy
SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures is a public Anthem Blue Cross and Blue Shield Nevada policy (policy SURG.00023). It lists 30 CPT or HCPCS codes, 25 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
- SURG.00023
- 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 |
|---|---|---|---|
| 00011 | Not listed | Policies naming 00011 | |
| 00023 | Not listed | Policies naming 00023 | |
| 00132 | Not listed | Policies naming 00132 | |
| 11920 | On the list | Tattooing To Correct Color Defects; 6.0 Sq Cm/< | Policies naming 11920 |
| 11921 | On the list | Tattooing To Correct Color Defects; 6.1-20.0 Sq Cm | Policies naming 11921 |
| 11922 | Not listed | Policies naming 11922 | |
| 15877 | On the list | Suction Assisted Lipectomy; Trunk | Policies naming 15877 |
| 17999 | Not listed | Policies naming 17999 | |
| 19316 | On the list | Mastopexy | Policies naming 19316 |
| 19318 | On the list | Breast reduction | Policies naming 19318 |
| 19325 | On the list | Breast augmentation with implant | Policies naming 19325 |
| 19328 | On the list | Removal of intact breast implant | Policies naming 19328 |
| 19330 | On the list | Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel) | Policies naming 19330 |
| 19340 | On the list | Insertion of breast implant on same day of mastectomy (ie, immediate) | Policies naming 19340 |
| 19342 | On the list | Insertion or replacement of breast implant on separate day from mastectomy | Policies naming 19342 |
| 19350 | On the list | Nipple/Areola Reconstruction | Policies naming 19350 |
| 19355 | On the list | Correction, Inverted Nipples | Policies naming 19355 |
| 19357 | On the list | Tissue expander placement in breast reconstruction, including subsequent expansion(s) | Policies naming 19357 |
| 19361 | On the list | Breast reconstruction; with latissimus dorsi flap | Policies naming 19361 |
| 19364 | On the list | Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap) | Policies naming 19364 |
| 19367 | On the list | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap | Policies naming 19367 |
| 19368 | On the list | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging) | Policies naming 19368 |
| 19369 | On the list | Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap | Policies naming 19369 |
| 19380 | On the list | Revision of reconstructed breast (eg, significant removal of tissue, re- advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision comb | Policies naming 19380 |
| 19396 | On the list | Preparation, Moulage, Custom Breast Implant | Policies naming 19396 |
| C1789 | On the list | Prosthesis, breast (implantable) | Policies naming C1789 |
| L8600 | On the list | Implant Breast Silicone/Eq | Policies naming L8600 |
| S2066 | On the list | Breast reconstruction with gluteal artery perforator (GAP) flap, including | Policies naming S2066 |
| S2067 | On the list | Breast reconstruction of a single breast with "stacked" deep inferior | Policies naming S2067 |
| S2068 | On the list | Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SI | Policies naming S2068 |
All Anthem Blue Cross and Blue Shield Nevada policies · Anthem Blue Cross and Blue Shield Nevada prior authorization CPT list