Anthem Blue Cross and Blue Shield Nevada prior authorization, page 31
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 |
|---|---|---|
| 63302 | Vertebral Corpectomy, 1 Segment; Extradural, Thoracic, Thoracolumbar Approach | Nevada Prior Authorization List, Pg 69 Original policy |
| 63303 | Vertebral Corpectomy, 1 Segment; Extradural, Lumbar/Sacral, Transperitoneal/Retroperitoneal Approach | Nevada Prior Authorization List, Pg 69 Original policy |
| 63304 | Vertebral Corpectomy, 1 Segment; Intradural, Cervical | Nevada Prior Authorization List, Pg 69 Original policy |
| 63305 | Vertebral Corpectomy, 1 Segment; Intradural, Thoracic, Transthoracic Approach | Nevada Prior Authorization List, Pg 69 Original policy |
| 63306 | Vertebral Corpectomy, 1 Segment; Intradural, Thoracic, Thoracolumbar Approach | Nevada Prior Authorization List, Pg 69 Original policy |
| 63307 | Vertebral Corpectomy, 1 Segment; Intradural, Lumbar/Sacral, Transperitoneal/Retroperitoneal Approach | Nevada Prior Authorization List, Pg 69 Original policy |
| 63308 | Vertebral Corpectomy, Add'l Segment | Nevada Prior Authorization List, Pg 69 Original policy |
| 63620 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion | Nevada Prior Authorization List, Pg 69 Original policy |
| 63650 | Percutaneous Implantation, Neurostimulator Electrode Array, Epidural | Nevada Prior Authorization List, Pg 69 Original policy |
| 63655 | Laminectomy, Implantation, Neurostimulator Electrodes, Plate/Paddle, Epidural | Nevada Prior Authorization List, Pg 70 Original policy |
| 63663 | Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including flu | Nevada Prior Authorization List, Pg 70 Original policy |
| 63664 | Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotom | Nevada Prior Authorization List, Pg 70 Original policy |
| 63685 | Insertion or replacement of spinal neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receive | Nevada Prior Authorization List, Pg 70 Original policy |
| 63688 | Revision or removal of implanted spinal neurostimulator pulse generator or receiver, with detachable connection to electrode array | Nevada Prior Authorization List, Pg 70 Original policy |
| 64405 | Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve | Nevada Prior Authorization List, Pg 70 Original policy |
| 64415 | Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed | Nevada Prior Authorization List, Pg 70 Original policy |
| 64417 | Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance, when performed | Nevada Prior Authorization List, Pg 70 Original policy |
| 64447 | Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance, when performed | Nevada Prior Authorization List, Pg 70 Original policy |
| 64450 | Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch | Nevada Prior Authorization List, Pg 70 Original policy |
| 64454 | Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed | Nevada Prior Authorization List, Pg 70 Original policy |
| 64479 | Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level | Nevada Prior Authorization List, Pg 70 Original policy |
| 64480 | Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (List separat | Nevada Prior Authorization List, Pg 70 Original policy |
| 64483 | Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level | Nevada Prior Authorization List, Pg 70 Original policy |
| 64484 | Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately | Nevada Prior Authorization List, Pg 70 Original policy |
| 64490 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Nevada Prior Authorization List, Pg 70 Original policy |
| 64491 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Nevada Prior Authorization List, Pg 70 Original policy |
| 64492 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Nevada Prior Authorization List, Pg 70 Original policy |
| 64493 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Nevada Prior Authorization List, Pg 70 Original policy |
| 64494 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Nevada Prior Authorization List, Pg 70 Original policy |
| 64495 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Nevada Prior Authorization List, Pg 71 Original policy |
| 64505 | Injection, Anesthetic Agent; Sphenopalatine Ganglion | Nevada Prior Authorization List, Pg 71 Original policy |
| 64510 | Injection, Anesthetic Agent; Stellate Ganglion (Cervical Sympathetic) | Nevada Prior Authorization List, Pg 71 Original policy |
| 64520 | Injection, Anesthetic Agent; Lumbar/Thoracic (Paravertebral Sympathetic) | Nevada Prior Authorization List, Pg 71 Original policy |
| 64553 | Percutaneous implantation of neurostimulator electrode array; cranial nerve | Nevada Prior Authorization List, Pg 71 Original policy |
| 64555 | Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) | Nevada Prior Authorization List, Pg 71 Original policy |
| 64561 | Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed | Nevada Prior Authorization List, Pg 71 Original policy |
| 64566 | Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming | Nevada Prior Authorization List, Pg 71 Original policy |
| 64568 | Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator | Nevada Prior Authorization List, Pg 71 Original policy |
| 64569 | Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator | Nevada Prior Authorization List, Pg 71 Original policy |
| 64575 | Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) | Nevada Prior Authorization List, Pg 71 Original policy |
| 64581 | Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) | Nevada Prior Authorization List, Pg 71 Original policy |
| 64582 | Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array | Nevada Prior Authorization List, Pg 71 Original policy |
| 64585 | Revision or removal of peripheral neurostimulator electrode array | Nevada Prior Authorization List, Pg 71 Original policy |
| 64590 | Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pu | Nevada Prior Authorization List, Pg 71 Original policy |
| 64596 | Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode arra | Nevada Prior Authorization List, Pg 71 Original policy |
| 64600 | Destruction, Neurolytic, Trigeminal Nerve; Supraorbital/Infraorbital/Mental/Inferior Alveolar | Nevada Prior Authorization List, Pg 71 Original policy |
| 64605 | Destruction, Neurolytic, Trigeminal Nerve; 2nd & 3rd Division | Nevada Prior Authorization List, Pg 71 Original policy |
| 64610 | Destruction, Neurolytic, Trigeminal Nerve; 2nd & 3rd Division W/Radiologic Monitoring | Nevada Prior Authorization List, Pg 71 Original policy |
| 64624 | Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed | Nevada Prior Authorization List, Pg 71 Original policy |
| 64625 | Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) | Nevada Prior Authorization List, Pg 72 Original policy |