Anthem Blue Cross and Blue Shield Nevada prior authorization, page 28
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 |
|---|---|---|
| 58210 | Radical Abdominal Hysterectomy W/Bilat Pelvic Lymphadenectomy | Nevada Prior Authorization List, Pg 61 Original policy |
| 58240 | Pelvic Exenteration, Gynecologic Malignancy | Nevada Prior Authorization List, Pg 61 Original policy |
| 58260 | Vaginal hysterectomy, for uterus 250 g or less | Nevada Prior Authorization List, Pg 61 Original policy |
| 58262 | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s) | Nevada Prior Authorization List, Pg 61 Original policy |
| 58263 | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele | Nevada Prior Authorization List, Pg 61 Original policy |
| 58267 | Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra typ | Nevada Prior Authorization List, Pg 61 Original policy |
| 58270 | Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele | Nevada Prior Authorization List, Pg 61 Original policy |
| 58275 | Vaginal Hysterectomy, W/Total/Partial Vaginectomy | Nevada Prior Authorization List, Pg 61 Original policy |
| 58280 | Vaginal Hysterectomy; W/Total/Partial Vaginectomy; W/Repair, Enterocele | Nevada Prior Authorization List, Pg 61 Original policy |
| 58285 | Vaginal Hysterectomy; Radical | Nevada Prior Authorization List, Pg 61 Original policy |
| 58290 | Vaginal Hysterectomy, Uterus >250 Gms | Nevada Prior Authorization List, Pg 61 Original policy |
| 58291 | Vaginal Hysterectomy, Uterus >250 Gms; W/Removal, Tube(S) &/Or Ovary(S) | Nevada Prior Authorization List, Pg 61 Original policy |
| 58292 | Vaginal Hysterectomy, Uterus >250 Gms; W/Removal, Tube(S) &/Or Ovary(S) W/Repair Of Enterocele | Nevada Prior Authorization List, Pg 61 Original policy |
| 58293 | Vaginal hysterectomy, for uterus greater than 250 g; with colpo- urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control | Nevada Prior Authorization List, Pg 61 Original policy |
| 58294 | Vaginal Hysterectomy, Uterus >250 Gms; W/Repair Of Enterocele | Nevada Prior Authorization List, Pg 61 Original policy |
| 58346 | Insertion, Heyman Capsules, Clinical Brachytherapy | Nevada Prior Authorization List, Pg 61 Original policy |
| 58353 | Ablation, Endometrial, Thermal, W/O Hysteroscopic Guidance | Nevada Prior Authorization List, Pg 61 Original policy |
| 58541 | Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less | Nevada Prior Authorization List, Pg 61 Original policy |
| 58542 | Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) | Nevada Prior Authorization List, Pg 61 Original policy |
| 58543 | Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g | Nevada Prior Authorization List, Pg 62 Original policy |
| 58544 | Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s | Nevada Prior Authorization List, Pg 62 Original policy |
| 58545 | Laparoscopy, Surg, Myomectomy; 1-4 Intramural Myomas, Total Wt 250 Gms, &/Or Remove Surface Myomas | Nevada Prior Authorization List, Pg 62 Original policy |
| 58546 | Laparoscopy, Surg, Myomectomy; 5/> Intramural Myomas &/Or Total Wt >250 Gms | Nevada Prior Authorization List, Pg 62 Original policy |
| 58548 | Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node | Nevada Prior Authorization List, Pg 62 Original policy |
| 58550 | Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus 250gms/< | Nevada Prior Authorization List, Pg 62 Original policy |
| 58552 | Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus 250gms/<; W/Removal, Tube(S) &/Or Ovary(S) | Nevada Prior Authorization List, Pg 62 Original policy |
| 58553 | Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus >250gms | Nevada Prior Authorization List, Pg 62 Original policy |
| 58554 | Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus >250gms; W/Remove Tube(S) &/Or Ovary(S) | Nevada Prior Authorization List, Pg 62 Original policy |
| 58558 | Hysteroscopy, Surgical; W/Endometrial Bx &/Or Polypectomy W/Wo D&C | Nevada Prior Authorization List, Pg 62 Original policy |
| 58560 | Hysteroscopy, Surgical; W/Division/Resection Intrauterine Septum, Any Method | Nevada Prior Authorization List, Pg 62 Original policy |
| 58561 | Hysteroscopy, Surgical; W/Removal Leiomyomata | Nevada Prior Authorization List, Pg 62 Original policy |
| 58562 | Hysteroscopy, Surgical, W/Removal Impacted Fb | Nevada Prior Authorization List, Pg 62 Original policy |
| 58563 | Hysteroscopy, Surgical; W/Endometrial Ablation | Nevada Prior Authorization List, Pg 62 Original policy |
| 58565 | Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants | Nevada Prior Authorization List, Pg 62 Original policy |
| 58570 | Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less | Nevada Prior Authorization List, Pg 62 Original policy |
| 58571 | Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less;with removal of tube(s) and/or ovary (s) | Nevada Prior Authorization List, Pg 62 Original policy |
| 58572 | Laparoscopy; surgical, with total hysterectomy, for uterus greater than 250 g | Nevada Prior Authorization List, Pg 62 Original policy |
| 58573 | Laparoscopy; surgical, with total hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary (s) | Nevada Prior Authorization List, Pg 62 Original policy |
| 58575 | Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when perfor | Nevada Prior Authorization List, Pg 62 Original policy |
| 58580 | Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency | Nevada Prior Authorization List, Pg 63 Original policy |
| 58660 | Laparoscopy, Surgical; W/Lysis, Adhesions (Salpingolysis/Ovariolysis) (Sep Proc) | Nevada Prior Authorization List, Pg 63 Original policy |
| 58661 | Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) | Nevada Prior Authorization List, Pg 63 Original policy |
| 58662 | Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by an | Nevada Prior Authorization List, Pg 63 Original policy |
| 58670 | Laparoscopy, surgical; with fulguration of oviducts (with or without transection) | Nevada Prior Authorization List, Pg 63 Original policy |
| 58671 | Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) | Nevada Prior Authorization List, Pg 63 Original policy |
| 58674 | Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency. | Nevada Prior Authorization List, Pg 63 Original policy |
| 58700 | Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) | Nevada Prior Authorization List, Pg 63 Original policy |
| 58925 | Ovarian Cystectomy, Unilat/Bilat | Nevada Prior Authorization List, Pg 63 Original policy |
| 58953 | Bilat Salpingo-Oophorect W/Omentect, Total Abdom Hyster & Radical Dissect Debulk | Nevada Prior Authorization List, Pg 63 Original policy |
| 58954 | Bilat Salping-Oophorec W/Omentec, Tl Abd Hyst & Radcl Dissec, Debul; W/Pelv & Ltd Paraaortic Lymp | Nevada Prior Authorization List, Pg 63 Original policy |