Anthem Blue Cross and Blue Shield Nevada prior authorization, page 27
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 |
|---|---|---|
| 57210 | Colpoperineorrhaphy, Suture, Injury, Vagina &/Or Perineum (Nonobstetrical) | Nevada Prior Authorization List, Pg 58 Original policy |
| 57240 | Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when performed | Nevada Prior Authorization List, Pg 58 Original policy |
| 57250 | Posterior Colporrhaphy, Repair, Rectocele W/Wo Perineorrhaphy | Nevada Prior Authorization List, Pg 59 Original policy |
| 57260 | Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed | Nevada Prior Authorization List, Pg 59 Original policy |
| 57265 | Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed; with enterocele repair | Nevada Prior Authorization List, Pg 59 Original policy |
| 57268 | Repair, Enterocele, Vaginal Approach (Sep Proc) | Nevada Prior Authorization List, Pg 59 Original policy |
| 57270 | Repair, Enterocele, Abdominal Approach (Sep Proc) | Nevada Prior Authorization List, Pg 59 Original policy |
| 57280 | Colpopexy, Abdominal Approach | Nevada Prior Authorization List, Pg 59 Original policy |
| 57282 | Sacrospinous Ligament Fixation, Prolapse, Vagina | Nevada Prior Authorization List, Pg 59 Original policy |
| 57283 | Colpopexy, Vaginal; Intra-Peritoneal Approach (Uterosacral, Levator Myorrhaphy) | Nevada Prior Authorization List, Pg 59 Original policy |
| 57284 | Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach | Nevada Prior Authorization List, Pg 59 Original policy |
| 57285 | Paravaginal defect repair (including repair of cystocele, if performed) ;vaginal approach | Nevada Prior Authorization List, Pg 59 Original policy |
| 57287 | Removal/Revision, Sling, Stress Incontinence | Nevada Prior Authorization List, Pg 59 Original policy |
| 57288 | Sling Operation, Stress Incontinence | Nevada Prior Authorization List, Pg 59 Original policy |
| 57291 | Construction, Artificial Vagina; W/O Graft | Nevada Prior Authorization List, Pg 59 Original policy |
| 57292 | Construction, Artificial Vagina; W/Graft | Nevada Prior Authorization List, Pg 59 Original policy |
| 57295 | Revision (including removal) of prosthetic vaginal graft, vaginal approach | Nevada Prior Authorization List, Pg 59 Original policy |
| 57296 | Revision (including removal) of prosthetic vaginal graft; open abdominal approach | Nevada Prior Authorization List, Pg 59 Original policy |
| 57300 | Closure, Rectovaginal Fistula; Vaginal/Transanal Approach | Nevada Prior Authorization List, Pg 59 Original policy |
| 57335 | Vaginoplasty, Intersex State | Nevada Prior Authorization List, Pg 59 Original policy |
| 57400 | Dilation of vagina under anesthesia (other than local) | Nevada Prior Authorization List, Pg 59 Original policy |
| 57410 | Pelvic examination under anesthesia (other than local) | Nevada Prior Authorization List, Pg 59 Original policy |
| 57415 | Removal of impacted vaginal foreign body (separate procedure) under anesthesia (other than local) | Nevada Prior Authorization List, Pg 59 Original policy |
| 57420 | Colposcopy, Entire Vagina, W/Cervix If Present | Nevada Prior Authorization List, Pg 59 Original policy |
| 57421 | Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix | Nevada Prior Authorization List, Pg 59 Original policy |
| 57423 | Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach | Nevada Prior Authorization List, Pg 60 Original policy |
| 57425 | Laparoscopy, Surgical, Colpopexy (Suspension of Vaginal Apex) | Nevada Prior Authorization List, Pg 60 Original policy |
| 57426 | Revision (including removal) of prosthetic vaginal graft, laparoscopic approach | Nevada Prior Authorization List, Pg 60 Original policy |
| 57452 | Colposcopy, Cervix W/Upper Adjacent Vagina | Nevada Prior Authorization List, Pg 60 Original policy |
| 57454 | Colposcopy, Cervix W/Upper Adjacent Vagina; W/Biopsy(S), Cervix & Endocervical Curettage | Nevada Prior Authorization List, Pg 60 Original policy |
| 57456 | Colposcopy, Cervix W/Upper Adjacent Vagina; W/Endocervical Curettage | Nevada Prior Authorization List, Pg 60 Original policy |
| 57461 | Colposcopy, Cervix W/Upper Adjacent Vagina; W/Loop Electrode Conization, Cervix | Nevada Prior Authorization List, Pg 60 Original policy |
| 57500 | Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure) | Nevada Prior Authorization List, Pg 60 Original policy |
| 57505 | Endocervical Curettage (Not Done As Part Of A Dilation & Curettage) | Nevada Prior Authorization List, Pg 60 Original policy |
| 57510 | Cauterization, Cervix; Electro/Thermal | Nevada Prior Authorization List, Pg 60 Original policy |
| 57511 | Cauterization, Cervix; Cryocautery, Initial/Repeat | Nevada Prior Authorization List, Pg 60 Original policy |
| 57513 | Cauterization, Cervix; Laser Ablation | Nevada Prior Authorization List, Pg 60 Original policy |
| 57520 | Conization, Cervix W/Wo Fulguration, W/Wo D&C/Repair; Cold Knife/Laser | Nevada Prior Authorization List, Pg 60 Original policy |
| 57522 | Conization, Cervix W/Wo Fulguration, W/Wo D&C/Repair; Loop | Nevada Prior Authorization List, Pg 60 Original policy |
| 57530 | Trachelectomy (Cervicectomy), Amputation, Cervix (Sep Proc) | Nevada Prior Authorization List, Pg 60 Original policy |
| 57700 | Cerclage, Uterine Cervix, Nonobstetrical | Nevada Prior Authorization List, Pg 60 Original policy |
| 57720 | Trachelorrhaphy, Plastic Repair, Uterine Cervix, Vaginal Approach | Nevada Prior Authorization List, Pg 60 Original policy |
| 57800 | Dilation, Cervical Canal, Instrumental (Sep Proc) | Nevada Prior Authorization List, Pg 60 Original policy |
| 58100 | Endometrial Bx W/Wo Endocervical Bx, W/O Dilation, Any Method (Sep Proc) | Nevada Prior Authorization List, Pg 60 Original policy |
| 58120 | Dilation & Curettage, Dx &/Or Therapeutic (Nonobstetrical) | Nevada Prior Authorization List, Pg 60 Original policy |
| 58145 | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or | Nevada Prior Authorization List, Pg 60 Original policy |
| 58150 | Total Abdominal Hysterectomy W/Wo Removal Tube(S)/Ovary(S) | Nevada Prior Authorization List, Pg 60 Original policy |
| 58152 | Total Abdominal Hysterectomy W/Wo Removal Tube(S)/Ovary(S); W/Colpo- Urethrocystopexy | Nevada Prior Authorization List, Pg 60 Original policy |
| 58180 | Supracervical Abdominal Hysterectomy, W/Wo Removal Tube(S)/Ovary(S) | Nevada Prior Authorization List, Pg 60 Original policy |
| 58200 | Total Abdominal Hysterectomy, W/Partial Vaginect, W/Pelvic Node Sample, W/Wo Rem Tubes/Ovaries | Nevada Prior Authorization List, Pg 61 Original policy |