Anthem Blue Cross and Blue Shield Nevada prior authorization, page 23
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 |
|---|---|---|
| 49653 | Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when perform | Nevada Prior Authorization List, Pg 51 Original policy |
| 49654 | Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible | Nevada Prior Authorization List, Pg 51 Original policy |
| 49655 | Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated | Nevada Prior Authorization List, Pg 51 Original policy |
| 49656 | Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible | Nevada Prior Authorization List, Pg 51 Original policy |
| 49900 | Suture, Secondary, Abdominal Wall, Evisceration/Dehiscence | Nevada Prior Authorization List, Pg 51 Original policy |
| 50250 | Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed | Nevada Prior Authorization List, Pg 51 Original policy |
| 50300 | Donor Nephrectomy; Cadaver Donor, Unilat/Bilat W/Prep & Maintenance, Allograft | Nevada Prior Authorization List, Pg 51 Original policy |
| 50320 | Donor Nephrectomy, Open, Living Donor W/O Allograft Preparation & Maintenance | Nevada Prior Authorization List, Pg 51 Original policy |
| 50323 | Backbench Standard Preparation Of Cadaver Donor Renal Allograft | Nevada Prior Authorization List, Pg 51 Original policy |
| 50325 | Backbench Standard Preparation Of Living Donor Renal Allograft (Open Or Laparoscopic) | Nevada Prior Authorization List, Pg 51 Original policy |
| 50327 | Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Venous Anastomosis, Each | Nevada Prior Authorization List, Pg 52 Original policy |
| 50328 | Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Arterial Anastomosis, Each | Nevada Prior Authorization List, Pg 52 Original policy |
| 50329 | Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Ureteral Anastomosis, Each | Nevada Prior Authorization List, Pg 52 Original policy |
| 50340 | Recipient Nephrectomy (Sep Proc) | Nevada Prior Authorization List, Pg 52 Original policy |
| 50360 | Renal Allotransplantation, Implantation, Graft; W/O Donor & Recipient Nephrectomy | Nevada Prior Authorization List, Pg 52 Original policy |
| 50365 | Renal Allotransplantation, Implantation, Graft; W/Recipient Nephrectomy | Nevada Prior Authorization List, Pg 52 Original policy |
| 50435 | Exchange nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all | Nevada Prior Authorization List, Pg 52 Original policy |
| 50542 | Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when performed | Nevada Prior Authorization List, Pg 52 Original policy |
| 50547 | Laparoscopy, Surgical; Donor Nephrectomy, Living Donor W/O Allograft Prep & Maintenance | Nevada Prior Authorization List, Pg 52 Original policy |
| 50575 | Renal Endoscopy Through Nephrotomy/Pyelotomy; W/Endopyelotomy | Nevada Prior Authorization List, Pg 52 Original policy |
| 50590 | Lithotripsy, Extracorporeal Shock Wave | Nevada Prior Authorization List, Pg 52 Original policy |
| 50592 | Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency | Nevada Prior Authorization List, Pg 52 Original policy |
| 50593 | Ablation, renal tumor(s), unilateral, presutaneous cryotherapy | Nevada Prior Authorization List, Pg 52 Original policy |
| 50688 | Change of ureterostomy tube or externally accessible ureteral stent via ileal conduit | Nevada Prior Authorization List, Pg 52 Original policy |
| 51040 | Cystostomy, Cystotomy W/Drainage | Nevada Prior Authorization List, Pg 52 Original policy |
| 51102 | Aspiration of bladder, with insertion of suprapubic catheter | Nevada Prior Authorization List, Pg 52 Original policy |
| 51600 | Injection Proc, Cystography/Voiding Urethrocystography | Nevada Prior Authorization List, Pg 52 Original policy |
| 51610 | Injection Proc, Retrograde Urethrocystography | Nevada Prior Authorization List, Pg 52 Original policy |
| 51702 | Insertion, Temporary Indwelling Bladder Catheter; Simple | Nevada Prior Authorization List, Pg 52 Original policy |
| 51710 | Change, Cystostomy Tube; Complicated | Nevada Prior Authorization List, Pg 52 Original policy |
| 51715 | Endoscopic Injection, Implant Matl Into Submucosal Tissues, Urethra &/Or Bladder Neck | Nevada Prior Authorization List, Pg 52 Original policy |
| 51720 | Bladder instillation of anticarcinogenic agent (including retention time) | Nevada Prior Authorization List, Pg 52 Original policy |
| 51721 | Transurethral ablation transducer insertion for delivery of thermal ultrasound for prostate | Nevada Prior Authorization List, Pg 52 Original policy |
| 51726 | Complex cystometrogram (ie, calibrated electronic equipment) | Nevada Prior Authorization List, Pg 52 Original policy |
| 51728 | Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressur | Nevada Prior Authorization List, Pg 52 Original policy |
| 51729 | Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressur | Nevada Prior Authorization List, Pg 53 Original policy |
| 52000 | Cystourethroscopy (Sep Proc) | Nevada Prior Authorization List, Pg 53 Original policy |
| 52001 | Cystourethroscopy W/Irrigation & Evacuation Clots | Nevada Prior Authorization List, Pg 53 Original policy |
| 52005 | Cystourethroscopy, W/Ureteral Catheterization | Nevada Prior Authorization List, Pg 53 Original policy |
| 52007 | Cystourethroscopy, W/Ureteral Catheterization; W/Brush Bx, Ureter &/Or Renal Pelvis | Nevada Prior Authorization List, Pg 53 Original policy |
| 52204 | Cystourethroscopy, with biopsy(s) | Nevada Prior Authorization List, Pg 53 Original policy |
| 52214 | Cystourethroscopy, W/Fulguration Trigone/Bladder Neck/Prostate/Urethra/Glands | Nevada Prior Authorization List, Pg 53 Original policy |
| 52224 | Cystourethroscopy, W/Fulguration/Treatment Lesion(S) < 0.5 Cm, W/Wo Bx | Nevada Prior Authorization List, Pg 53 Original policy |
| 52234 | Cystourethroscopy, W/Fulguration &/Or Resection; Bladder Tumor(S) 0.5-2.0 Cm | Nevada Prior Authorization List, Pg 53 Original policy |
| 52235 | Cystourethroscopy, W/Fulguration &/Or Resection; Bladder Tumor(S) 2.0-5.0 Cm | Nevada Prior Authorization List, Pg 53 Original policy |
| 52240 | Cystourethroscopy, W/Fulguration &/Or Resection; Large Bladder Tumor(S) > 5.0 Cm | Nevada Prior Authorization List, Pg 53 Original policy |
| 52260 | Cystourethroscopy, W/Dilation, Bladder, Interstitial Cystitis; General/Spinal Anesthesia | Nevada Prior Authorization List, Pg 53 Original policy |
| 52265 | Cystourethroscopy, W/Dilation, Bladder, Interstitial Cystitis; Local Anesthesia | Nevada Prior Authorization List, Pg 53 Original policy |
| 52275 | Cystourethroscopy, W/Int Urethrotomy; Male | Nevada Prior Authorization List, Pg 53 Original policy |
| 52276 | Cystourethroscopy, W/Direct Vision Int Urethrotomy | Nevada Prior Authorization List, Pg 53 Original policy |