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Anthem Blue Cross and Blue Shield Nevada prior authorization, page 29

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
CodeDescriptionSource
58956Bilateral Salpingo-Oophorectomy With Total Omentectomy, Total Abdominal Hysterectomy For MalignancyNevada Prior Authorization List, Pg 63 Original policy
59200Insertion, Cervical Dilator (Sep Proc)Nevada Prior Authorization List, Pg 63 Original policy
60660Percutaneous ablation of 1 or more thyroid nodule(s)Nevada Prior Authorization List, Pg 63 Original policy
61215Insertion, Subq Reservoir/Pump/Infusion System, Ventricular CatheterNevada Prior Authorization List, Pg 63 Original policy
61630Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneousNevada Prior Authorization List, Pg 63 Original policy
61635Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angiopNevada Prior Authorization List, Pg 63 Original policy
61715MRI guided focused ultrasound high intensity stereotactic intracranial ablationNevada Prior Authorization List, Pg 63 Original policy
61736Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 siNevada Prior Authorization List, Pg 63 Original policy
61737Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; multiple trajectories forNevada Prior Authorization List, Pg 63 Original policy
61790Creation, Lesion, Stereotactic, Percutaneous, Neurolytic Agent; Gasserian GanglionNevada Prior Authorization List, Pg 63 Original policy
61791Creation, Lesion, Stereotactic, Percutaneous, Neurolytic Agent; Trigeminal Medullary TractNevada Prior Authorization List, Pg 64 Original policy
61796Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesionNevada Prior Authorization List, Pg 64 Original policy
61798Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesionNevada Prior Authorization List, Pg 64 Original policy
61850Twist Drill/Burr Hole(S), Implantation, Neurostimulator Electrodes, CorticalNevada Prior Authorization List, Pg 64 Original policy
61860Craniectomy/Craniotomy, Implantation, Neurostimulator Electrodes, Cerebral, CorticalNevada Prior Authorization List, Pg 64 Original policy
61863Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, wo Intraop Microelectrode Recording; First ArrayNevada Prior Authorization List, Pg 64 Original policy
61867Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, w Intraop Microelectrode Recording; First ArrayNevada Prior Authorization List, Pg 64 Original policy
61885Subq Placement Cranial Neurostimulator Pulse Generator/Receiver; W/Connection Sngle Electrod ArrayNevada Prior Authorization List, Pg 64 Original policy
61886Subq Placement Cranial Neurostimulator Pulse Generator/Receiver; W/Connection 2+ Electrode ArraysNevada Prior Authorization List, Pg 64 Original policy
61889Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, when performed, with direct or inductive coupling, with coNevada Prior Authorization List, Pg 64 Original policy
61891Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode array(s)Nevada Prior Authorization List, Pg 64 Original policy
62263Lysis, Perq, Epidural Adhesions, Solution Injection/Mechanical W/Radiologic Localization; 2 Days/>Nevada Prior Authorization List, Pg 64 Original policy
62264Lysis, Perq Epidural Adhesions, Solution Injection/Mechanical W/Radiologic Localization; 1 DayNevada Prior Authorization List, Pg 64 Original policy
62281Injection/Infusion Neurolytic Substance, W/Wo Therapeutic Substance; Epidural Cervical/ThoracicNevada Prior Authorization List, Pg 64 Original policy
62282Injection/Infusion Neurolytic Substance; Epidural, Lumbar/CaudalNevada Prior Authorization List, Pg 64 Original policy
62287Decompression, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle-based technique to remove disc material under fluoroscopic imaging or otheNevada Prior Authorization List, Pg 64 Original policy
62290Injection, Diskography, Each Level; LumbarNevada Prior Authorization List, Pg 64 Original policy
62291Injection, Diskography, Each Level; Cervical/ThoracicNevada Prior Authorization List, Pg 64 Original policy
62320Injection(s) of diagnostic or therapeutic substance(s) (eg. anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needleNevada Prior Authorization List, Pg 64 Original policy
62321Injection(s) of diagnostic or therapeutic substance(s) (eg. anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needleNevada Prior Authorization List, Pg 64 Original policy
62322Injection(s) of diagnostic or therapeutic substances(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution) not including neurolytic substances, including needleNevada Prior Authorization List, Pg 65 Original policy
62323Injection(s) of diagnostic or therapeutic substances(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution) not including neurolytic substances, including needleNevada Prior Authorization List, Pg 65 Original policy
62350Implant/Revisn/Reposition Intrathecal/Epidural Catheter, Externl Reservor/Infusion Pump; W/O LaminctNevada Prior Authorization List, Pg 65 Original policy
62351Implant/Revisn/Reposition Intrathecal/Epidural Catheter, Externl Reservor/Infusion Pump; W/LaminectNevada Prior Authorization List, Pg 65 Original policy
62360Implantation/Replace, Device, Intrathecal/Epidural Drug Infusion; Subq ReservoirNevada Prior Authorization List, Pg 65 Original policy
62361Implantation/Replace, Device, Intrathecal/Epidural Drug Infusion; Non- Programmable PumpNevada Prior Authorization List, Pg 65 Original policy
62362Implantation/Replace, Device, Intrathecal/Epidural Drug Infusion; Programmable PumpNevada Prior Authorization List, Pg 65 Original policy
62380Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc; 1Nevada Prior Authorization List, Pg 65 Original policy
63001Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral sNevada Prior Authorization List, Pg 65 Original policy
63003Laminectomy, W/O Facetectomy/Foraminotomy/Diskectomy, 1/2 Segments; ThoracicNevada Prior Authorization List, Pg 65 Original policy
63005Laminectomy W/O Facetectomy/Foraminotomy/Diskectomy, 1/2 Segments; LumbarNevada Prior Authorization List, Pg 65 Original policy
63012Laminectomy W/Removal, Abnormal Facets, LumbarNevada Prior Authorization List, Pg 65 Original policy
63015Laminectomy W/O Facetectomy/Foraminotomy/Diskectomy, > 2 Segments; CervicalNevada Prior Authorization List, Pg 65 Original policy
63016Laminectomy W/O Facetectomy/Foraminotomy/Diskectomy, > 2 Segments; ThoracicNevada Prior Authorization List, Pg 65 Original policy
63017Laminectomy W/O Facetectomy/Foraminotomy/Diskectomy, > 2 Segments; LumbarNevada Prior Authorization List, Pg 65 Original policy
63020Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspaceNevada Prior Authorization List, Pg 65 Original policy
63030Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspaceNevada Prior Authorization List, Pg 65 Original policy
63035Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additionaNevada Prior Authorization List, Pg 66 Original policy
63040Laminotomy W/Partl Facetectmy/Foramnotmy/Herniated Diskect, Re- Exploratn, Sngle Interspc; CervicalNevada Prior Authorization List, Pg 66 Original policy
63042Laminotomy W/Partl Facetectomy/Foraminotomy/Herniated Diskect, Re- Explor, Sngle Interspc; LumbarNevada Prior Authorization List, Pg 66 Original policy

Sources

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The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

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