Anthem Blue Cross and Blue Shield Nevada prior authorization, page 25

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

Prior authorization codes
Code	Description	Source
53605	Dilation, Urethral Stricture/Vesical Neck, Male, General/Spinal Anesthesia	Nevada Prior Authorization List, Pg 55 Original policy
53665	Dilation, Female Urethra, General/Conduction (Spinal) Anesthesia	Nevada Prior Authorization List, Pg 55 Original policy
53850	Transurethral Destruction, Prostate Tissue; Microwave Thermotherapy	Nevada Prior Authorization List, Pg 55 Original policy
53852	Transurethral Destruction, Prostate Tissue; Radiofrequency Thermotherapy	Nevada Prior Authorization List, Pg 55 Original policy
53860	Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence	Nevada Prior Authorization List, Pg 55 Original policy
54001	Slitting, Prepuce, Dorsal/Lateral (Sep Proc); Except Newborn	Nevada Prior Authorization List, Pg 55 Original policy
54055	Destruction, Penile Lesion, Simple; Electrodesiccation	Nevada Prior Authorization List, Pg 55 Original policy
54057	Destruction, Penile Lesion, Simple; Laser Surgery	Nevada Prior Authorization List, Pg 55 Original policy
54060	Destruction, Penile Lesion, Simple; Surgical Excision	Nevada Prior Authorization List, Pg 55 Original policy
54065	Destruction, Penile Lesion, Extensive	Nevada Prior Authorization List, Pg 55 Original policy
54100	Bx Of Penis; (Sep Proc)	Nevada Prior Authorization List, Pg 55 Original policy
54110	Excision, Penile Plaque (Peyronie Disease)	Nevada Prior Authorization List, Pg 55 Original policy
54125	Amputation, Penis; Complete	Nevada Prior Authorization List, Pg 55 Original policy
54150	Circumcision, using clamp or other device with regional dorsal penile or ring block	Nevada Prior Authorization List, Pg 55 Original policy
54161	Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age	Nevada Prior Authorization List, Pg 55 Original policy
54162	Lysis/Excision, Penile Postcircumcision Adhesions	Nevada Prior Authorization List, Pg 55 Original policy
54163	Repair, Incomplete Circumcision	Nevada Prior Authorization List, Pg 55 Original policy
54164	Frenulotomy, Penis	Nevada Prior Authorization List, Pg 55 Original policy
54300	Plastic Operation, Penis, Straightening, Chordee, W/Wo Mobilization, Urethra	Nevada Prior Authorization List, Pg 55 Original policy
54360	Plastic Operation, Penis To Correct Angulation	Nevada Prior Authorization List, Pg 55 Original policy
54400	Insertion, Penile Prosthesis; Non-Inflatable (Semi-Rigid)	Nevada Prior Authorization List, Pg 55 Original policy
54401	Insertion, Penile Prosthesis; Inflatable (Self-Contained)	Nevada Prior Authorization List, Pg 55 Original policy
54405	Insertion, (Multi-Component) Inflatable Penile Prosthesis	Nevada Prior Authorization List, Pg 56 Original policy
54410	Removal & Replacement, Multi-Component Inflatable Penile Prosthesis, Same Session	Nevada Prior Authorization List, Pg 56 Original policy
54411	Removal & Replacement, Multi-Component Inflatable Penile Prosthesis, Infected, W/ Irrig & Debride	Nevada Prior Authorization List, Pg 56 Original policy
54416	Removal & Replacement, Non-Inflatable (Semi-Rigid)/Inflatable (Self-Contained) Penile Prosthesis	Nevada Prior Authorization List, Pg 56 Original policy
54417	Removal & Replace, Non-Inflatable/Inflatable Penile Prosthesis Infect, W/Irrig & Debride	Nevada Prior Authorization List, Pg 56 Original policy
54440	Plastic Operation, Penis, Injury	Nevada Prior Authorization List, Pg 56 Original policy
54450	Foreskin Manipulation W/Lysis, Preputial Adhesions & Stretching	Nevada Prior Authorization List, Pg 56 Original policy
54512	Excision, Extraparenchymal Lesion, Testis	Nevada Prior Authorization List, Pg 56 Original policy
54520	Orchiectomy, Simple, W/Wo Prosthesis, Scrotal/Inguinal Approach	Nevada Prior Authorization List, Pg 56 Original policy
54530	Orchiectomy, Radical, Tumor; Inguinal Approach	Nevada Prior Authorization List, Pg 56 Original policy
54600	Reduction, Torsion, Testis, Surgical, W/Wo Fixation, Contralateral Testis	Nevada Prior Authorization List, Pg 56 Original policy
54640	Orchiopexy, inguinal or scrotal approach	Nevada Prior Authorization List, Pg 56 Original policy
54660	Insertion, Testicular Prosthesis (Sep Proc)	Nevada Prior Authorization List, Pg 56 Original policy
54690	Laparoscopy, Surgical; Orchiectomy	Nevada Prior Authorization List, Pg 56 Original policy
54700	Incision & Drainage, Epididymis, Testis &/Or Scrotal Space	Nevada Prior Authorization List, Pg 56 Original policy
54830	Excision, Local Lesion, Epididymis	Nevada Prior Authorization List, Pg 56 Original policy
54840	Excision, Spermatocele, W/Wo Epididymectomy	Nevada Prior Authorization List, Pg 56 Original policy
54860	Epididymectomy; Unilat	Nevada Prior Authorization List, Pg 56 Original policy
55000	Puncture Aspiration, Hydrocele, Tunica Vaginalis, W/Wo Injection, Medication	Nevada Prior Authorization List, Pg 56 Original policy
55040	Excision, Hydrocele; Unilat	Nevada Prior Authorization List, Pg 56 Original policy
55041	Excision, Hydrocele; Bilat	Nevada Prior Authorization List, Pg 56 Original policy
55060	Repair, Tunica Vaginalis Hydrocele (Bottle Type)	Nevada Prior Authorization List, Pg 56 Original policy
55100	Drainage, Scrotal Wall Abscess	Nevada Prior Authorization List, Pg 56 Original policy
55110	Scrotal Exploration	Nevada Prior Authorization List, Pg 56 Original policy
55120	Removal, Fb In Scrotum	Nevada Prior Authorization List, Pg 56 Original policy
55180	Scrotoplasty; Complicated	Nevada Prior Authorization List, Pg 56 Original policy
55250	Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)	Nevada Prior Authorization List, Pg 57 Original policy
55400	Vasovasostomy, Vasovasorrhaphy	Nevada Prior Authorization List, Pg 57 Original policy

Sources

Nevada Prior Authorization List