Anthem Blue Cross and Blue Shield Nevada prior authorization, page 12
CPT code lookup
Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| 28289 | Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant | Nevada Prior Authorization List, Pg 27 Original policy |
| 28291 | Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint with implant | Nevada Prior Authorization List, Pg 27 Original policy |
| 28292 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with resection of proximal phalanx base, when performed, any method | Nevada Prior Authorization List, Pg 27 Original policy |
| 28295 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal metatarsal osteotomy, any method | Nevada Prior Authorization List, Pg 27 Original policy |
| 28296 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with distal metatarsal osteotomy, any method | Nevada Prior Authorization List, Pg 27 Original policy |
| 28297 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method | Nevada Prior Authorization List, Pg 27 Original policy |
| 28298 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal phalanx osteotomy, any method | Nevada Prior Authorization List, Pg 27 Original policy |
| 28299 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with double osteotomy, any method | Nevada Prior Authorization List, Pg 27 Original policy |
| 28306 | Osteotomy, Metatarsal, W/Wo Lengthening/Shortening/Ang Correction; 1st Metatarsal | Nevada Prior Authorization List, Pg 27 Original policy |
| 28307 | Osteotomy, Metatarsal, W/Wo Lengthening/Shortening/Ang Correction; 1st Metatarsal W/Autograft | Nevada Prior Authorization List, Pg 27 Original policy |
| 28308 | Osteotomy, Metatarsal, W/Wo Lengthening/Shortening/Ang Correction; Not 1st Metatarsal, Each | Nevada Prior Authorization List, Pg 27 Original policy |
| 28310 | Osteotomy, Shortening, Angular/Rotational Correction; Proximal Phalanx, 1st Toe (Sep Proc) | Nevada Prior Authorization List, Pg 27 Original policy |
| 28312 | Osteotomy, Shortening, Angular/Rotational Correction; Other Phalanges, Any Toe | Nevada Prior Authorization List, Pg 28 Original policy |
| 28315 | Sesamoidectomy, 1st Toe (Sep Proc) | Nevada Prior Authorization List, Pg 28 Original policy |
| 28446 | Open osteochondral autograft, talus (includes obtaining grafts) | Nevada Prior Authorization List, Pg 28 Original policy |
| 28750 | Arthrodesis, Great Toe; Metatarsophalangeal Joint | Nevada Prior Authorization List, Pg 28 Original policy |
| 28890 | Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guida | Nevada Prior Authorization List, Pg 28 Original policy |
| 29800 | Arthroscopy, Temporomandibular Joint, Dx W/Wo Synovial Bx (Sep Proc) | Nevada Prior Authorization List, Pg 28 Original policy |
| 29804 | Arthroscopy, Temporomandibular Joint, Surgical | Nevada Prior Authorization List, Pg 28 Original policy |
| 29805 | Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) | Nevada Prior Authorization List, Pg 28 Original policy |
| 29806 | Arthroscopy, shoulder, surgical; capsulorrhaphy | Nevada Prior Authorization List, Pg 28 Original policy |
| 29807 | Arthroscopy, shoulder, surgical; repair of SLAP lesion | Nevada Prior Authorization List, Pg 28 Original policy |
| 29819 | Arthroscopy, shoulder, surgical; with removal of loose body or foreign body | Nevada Prior Authorization List, Pg 28 Original policy |
| 29820 | Arthroscopy, shoulder, surgical; synovectomy, partial | Nevada Prior Authorization List, Pg 28 Original policy |
| 29821 | Arthroscopy, shoulder, surgical; synovectomy, complete | Nevada Prior Authorization List, Pg 28 Original policy |
| 29822 | Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, bi | Nevada Prior Authorization List, Pg 28 Original policy |
| 29823 | Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilag | Nevada Prior Authorization List, Pg 29 Original policy |
| 29824 | Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) | Nevada Prior Authorization List, Pg 29 Original policy |
| 29825 | Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation | Nevada Prior Authorization List, Pg 29 Original policy |
| 29826 | Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separatel | Nevada Prior Authorization List, Pg 29 Original policy |
| 29827 | Arthroscopy, shoulder, surgical; with rotator cuff repair | Nevada Prior Authorization List, Pg 29 Original policy |
| 29828 | Arthroscopy, shoulder, surgical; biceps tenodesis | Nevada Prior Authorization List, Pg 29 Original policy |
| 29860 | Arthroscopy, Hip, Dx W/Wo Synovial Bx (Sep Proc) | Nevada Prior Authorization List, Pg 29 Original policy |
| 29861 | Arthroscopy, Hip, Surgical; W/Removal, Loose/Foreign Body | Nevada Prior Authorization List, Pg 29 Original policy |
| 29862 | Arthroscopy, Hip, Surgical; W/Chondroplasty/Arthroplasty, &/Or Resection, Labrum | Nevada Prior Authorization List, Pg 29 Original policy |
| 29863 | Arthroscopy, Hip, Surgical; W/Synovectomy | Nevada Prior Authorization List, Pg 29 Original policy |
| 29866 | Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) | Nevada Prior Authorization List, Pg 29 Original policy |
| 29867 | Arthroscopy, Knee, Surgical; Osteochondral Allograft (Eg, Mosaicplasty) | Nevada Prior Authorization List, Pg 29 Original policy |
| 29868 | Arthroscopy, Knee, Surgical; Meniscal Transplantation (Includes Arthrotomy For Meniscal Insertion), Medial Or Lateral | Nevada Prior Authorization List, Pg 29 Original policy |
| 29870 | Arthroscopy, Knee, Dx, W/Wo Synovial Bx (Sep Proc) | Nevada Prior Authorization List, Pg 30 Original policy |
| 29871 | Arthroscopy, Knee, Surgical; Infection, Lavage & Drainage | Nevada Prior Authorization List, Pg 30 Original policy |
| 29873 | Arthroscopy, Knee, Surgical; W/Lateral Release | Nevada Prior Authorization List, Pg 30 Original policy |
| 29874 | Arthroscopy, Knee, Surgical; Removal, Loose/Fb | Nevada Prior Authorization List, Pg 30 Original policy |
| 29875 | Arthroscopy, Knee, Surgical; Synovectomy, Limited (Sep Proc) | Nevada Prior Authorization List, Pg 30 Original policy |
| 29876 | Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) | Nevada Prior Authorization List, Pg 30 Original policy |
| 29877 | Arthroscopy, Knee, Surgical; Debridement/Shaving, Articular Cartilage (Chondroplasty) | Nevada Prior Authorization List, Pg 30 Original policy |
| 29879 | Arthroscopy, Knee, Surgical; Abrasion Arthroplasty (W/Chondroplasty)/Multiple Drilling/Microfx | Nevada Prior Authorization List, Pg 30 Original policy |
| 29880 | Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same | Nevada Prior Authorization List, Pg 30 Original policy |
| 29881 | Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same o | Nevada Prior Authorization List, Pg 30 Original policy |
| 29882 | Arthroscopy, Knee, Surgical; W/Meniscus Repair, Medial/Lateral | Nevada Prior Authorization List, Pg 30 Original policy |