Anthem Blue Cross and Blue Shield Nevada prior authorization, page 3
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 |
|---|---|---|
| 13151 | Repair, Complex, Eyelids, Nose, Ears &/Or Lips; 1.1 To 2.5 Cm | Nevada Prior Authorization List, Pg 5 Original policy |
| 13152 | Repair, Complex, Eyelids, Nose, Ears &/Or Lips; 2.6 To 7.5 Cm | Nevada Prior Authorization List, Pg 5 Original policy |
| 13160 | Secondary Closure, Surgical Wound/Dehiscence, Extensive/Complicated | Nevada Prior Authorization List, Pg 5 Original policy |
| 14020 | Adjacent Tissue Transfer/Rearrangement, Scalp, Arms &/Or Legs; Defect 10 Sq Cm/< | Nevada Prior Authorization List, Pg 5 Original policy |
| 14040 | Adjacent Tissue Transfer, Forehead/Cheeks/Chin/Mouth/Neck/Axillae/Genitalia/Hands/Feet; 10 Sq Cm/< | Nevada Prior Authorization List, Pg 5 Original policy |
| 14041 | Adjacent Tissue Transfer, Forehead/Cheeks/Chin/Mouth/Neck/Axillae/Genitalia/Hands/Feet;10.1- 30.0sqcm | Nevada Prior Authorization List, Pg 5 Original policy |
| 14060 | Adjacent Tissue Transfer/Rearrangement, Eyelids/Nose/Ears/Lips; Defect 10 Sq Cm/< | Nevada Prior Authorization List, Pg 5 Original policy |
| 14061 | Adjacent Tissue Transfer/Rearrangement, Eyelids/Nose/Ears/Lips; Defect 10.1- 30.0 Sq Cm | Nevada Prior Authorization List, Pg 5 Original policy |
| 14301 | Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm | Nevada Prior Authorization List, Pg 6 Original policy |
| 15004 | Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutane | Nevada Prior Authorization List, Pg 6 Original policy |
| 15011 | Harvest of skin for autograft; first | Nevada Prior Authorization List, Pg 6 Original policy |
| 15013 | Preparation of skin autograft, requiring enzymatic processing,; first 25 sq cm or less | Nevada Prior Authorization List, Pg 6 Original policy |
| 15015 | Application of skin autograft; first 480 sq cm or less | Nevada Prior Authorization List, Pg 6 Original policy |
| 15017 | Application of skin autograft; first 480 sq cm or less | Nevada Prior Authorization List, Pg 6 Original policy |
| 15100 | Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and childr | Nevada Prior Authorization List, Pg 6 Original policy |
| 15120 | Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digi | Nevada Prior Authorization List, Pg 6 Original policy |
| 15150 | Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less | Nevada Prior Authorization List, Pg 6 Original policy |
| 15151 | Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) | Nevada Prior Authorization List, Pg 6 Original policy |
| 15155 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less | Nevada Prior Authorization List, Pg 6 Original policy |
| 15220 | Full Thickness Graft, Free, W/Closure Donor Site, Scalp/Arms/Legs; 20 Sq Cm/< | Nevada Prior Authorization List, Pg 6 Original policy |
| 15240 | Full Thickness Graft, Free, W/Closure Donor, Face/Neck/Axillae/Genitalia/Hands/Feet; 20 Sq Cm/< | Nevada Prior Authorization List, Pg 6 Original policy |
| 15260 | Full Thickness Graft, Free, W/Closure Donor Site, Nose/Ears/Eyelids/Lips; 20 Sq Cm/< | Nevada Prior Authorization List, Pg 6 Original policy |
| 15271 | Application Of Skin Substitute Graft To Trunk, Arms, Legs, Total Wound Surface Area Up To 100 Sq Cm; First 25 Sq Cm Or Less Wound Surface Area | Nevada Prior Authorization List, Pg 6 Original policy |
| 15273 | Application Of Skin Substitute Graft To Trunk, Arms, Legs, Total Wound Surface Area Greater Than Or Equal To 100 Sq Cm; First 100 Sq Cm Wound Surface Area, Or 1% Of Body Area | Nevada Prior Authorization List, Pg 6 Original policy |
| 15275 | Application Of Skin Substitute Graft To Face, Scalp, Eyelids, Mouth, Neck, Ears, Orbits, Genitalia, Hands, Feet, And/Or Multiple Digits, Total Wound Surface Area Up To 100 Sq | Nevada Prior Authorization List, Pg 6 Original policy |
| 15277 | Application Of Skin Substitute Graft To Face, Scalp, Eyelids, Mouth, Neck, Ears, Orbits, Genitalia, Hands, Feet, And/Or Multiple Digits, Total Wound Surface Area Greater Than | Nevada Prior Authorization List, Pg 6 Original policy |
| 15576 | Formation, Direct/Tubed Pedicle, W/Wo Transfer; Eyelids/Nose/Ears/Lips/Intraoral | Nevada Prior Authorization List, Pg 6 Original policy |
| 15760 | Graft; Composite, W/Primary Closure, Donor Area | Nevada Prior Authorization List, Pg 6 Original policy |
| 15769 | Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia) | Nevada Prior Authorization List, Pg 6 Original policy |
| 15770 | Graft; Derma-Fat-Fascia | Nevada Prior Authorization List, Pg 6 Original policy |
| 15771 | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate | Nevada Prior Authorization List, Pg 6 Original policy |
| 15773 | Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate | Nevada Prior Authorization List, Pg 6 Original policy |
| 15775 | Punch Graft, Hair Transplant; 1-15 Punch Grafts | Nevada Prior Authorization List, Pg 7 Original policy |
| 15776 | Punch Graft, Hair Transplant; > 15 Punch Grafts | Nevada Prior Authorization List, Pg 7 Original policy |
| 15780 | Dermabrasion; Total Face | Nevada Prior Authorization List, Pg 7 Original policy |
| 15781 | Dermabrasion; Segmental, Face | Nevada Prior Authorization List, Pg 7 Original policy |
| 15782 | Dermabrasion; Regional, Other Than Face | Nevada Prior Authorization List, Pg 7 Original policy |
| 15783 | Dermabrasion; Superficial, Any Site | Nevada Prior Authorization List, Pg 7 Original policy |
| 15786 | Abrasion; Single Lesion | Nevada Prior Authorization List, Pg 7 Original policy |
| 15788 | Chemical Peel, Facial; Epidermal | Nevada Prior Authorization List, Pg 7 Original policy |
| 15789 | Chemical Peel, Facial; Dermal | Nevada Prior Authorization List, Pg 7 Original policy |
| 15792 | Chemical Peel, Nonfacial; Epidermal | Nevada Prior Authorization List, Pg 7 Original policy |
| 15793 | Chemical Peel, Nonfacial; Dermal | Nevada Prior Authorization List, Pg 7 Original policy |
| 15820 | Blepharoplasty, Lower Eyelid | Nevada Prior Authorization List, Pg 7 Original policy |
| 15821 | Blepharoplasty, Lower Eyelid; W/Extensive Herniated Fat Pad | Nevada Prior Authorization List, Pg 7 Original policy |
| 15822 | Blepharoplasty, Upper Eyelid | Nevada Prior Authorization List, Pg 7 Original policy |
| 15823 | Blepharoplasty, Upper Eyelid; W/Excessive Skin Weighting Down Lid | Nevada Prior Authorization List, Pg 7 Original policy |
| 15824 | Rhytidectomy; Forehead | Nevada Prior Authorization List, Pg 7 Original policy |
| 15825 | Rhytidectomy; Neck W/Platysmal Tightening (Platysmal Flap, P-Flap) | Nevada Prior Authorization List, Pg 7 Original policy |
| 15826 | Rhytidectomy; Glabellar Frown Lines | Nevada Prior Authorization List, Pg 7 Original policy |