Anthem Blue Cross and Blue Shield Nevada prior authorization, page 38
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 |
|---|---|---|
| 73720 | Mri, Lower Extremity, Other Than Joint; W/O Contrast Matl(S), Followed Contrast Matl(S) & Furthr Seq | Nevada Prior Authorization List, Pg 82 Original policy |
| 73721 | Mri, Any Joint, Lower Extremity; W/O Contrast Matl | Nevada Prior Authorization List, Pg 82 Original policy |
| 73722 | Mri, Any Joint, Lower Extremity; W/Contrast Matl(S) | Nevada Prior Authorization List, Pg 83 Original policy |
| 73723 | Mri, Any Joint, Lower Extremity; W/O Contrast Matl(S), Followed By Contrast Matl(S) & Further Seq | Nevada Prior Authorization List, Pg 83 Original policy |
| 73725 | Mra, Lower Extremity, W/Wo Contrast | Nevada Prior Authorization List, Pg 83 Original policy |
| 74150 | Ct Scan, Abdomen; W/O Contrast | Nevada Prior Authorization List, Pg 83 Original policy |
| 74160 | Computed tomography, abdomen; with contrast material(s) | Nevada Prior Authorization List, Pg 83 Original policy |
| 74170 | Ct Scan, Abdomen; W/O Contrast, Then W/Contrast & Further Sections | Nevada Prior Authorization List, Pg 83 Original policy |
| 74174 | Computed Tomographic Angiography, Abdomen And Pelvis, With Contrast Material(S), Including Noncontrast Images, If Performed, And Image Postprocessing | Nevada Prior Authorization List, Pg 83 Original policy |
| 74175 | Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and im | Nevada Prior Authorization List, Pg 83 Original policy |
| 74176 | Computed tomography, abdomen and pelvis; without contrast material | Nevada Prior Authorization List, Pg 83 Original policy |
| 74177 | Computed tomography, abdomen and pelvis; with contrast material(s) | Nevada Prior Authorization List, Pg 83 Original policy |
| 74178 | Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regio | Nevada Prior Authorization List, Pg 83 Original policy |
| 74181 | Mri, Abdomen; W/O Contrast Matl(S) | Nevada Prior Authorization List, Pg 83 Original policy |
| 74182 | Mri, Abdomen; W/Contrast Matl(S) | Nevada Prior Authorization List, Pg 83 Original policy |
| 74183 | Mri, Abdomen; W/O Contrast Matl(S) Followed By Contrast Matl(S) & Further Sequences | Nevada Prior Authorization List, Pg 83 Original policy |
| 74185 | Mra, Abdomen, W/Wo Contrast | Nevada Prior Authorization List, Pg 83 Original policy |
| 74261 | Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material | Nevada Prior Authorization List, Pg 83 Original policy |
| 74262 | Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including | Nevada Prior Authorization List, Pg 83 Original policy |
| 74263 | Computed tomographic (CT) colonography, screening, including image postprocessing | Nevada Prior Authorization List, Pg 83 Original policy |
| 74712 | Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single of first gestation | Nevada Prior Authorization List, Pg 83 Original policy |
| 75557 | Cardiac magnetic resonance imaging for morphology and function without contrast material | Nevada Prior Authorization List, Pg 83 Original policy |
| 75559 | Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging | Nevada Prior Authorization List, Pg 83 Original policy |
| 75561 | Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast materi | Nevada Prior Authorization List, Pg 83 Original policy |
| 75563 | Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast materi | Nevada Prior Authorization List, Pg 83 Original policy |
| 75571 | Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium | Nevada Prior Authorization List, Pg 83 Original policy |
| 75572 | Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D ima | Nevada Prior Authorization List, Pg 83 Original policy |
| 75573 | Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postproce | Nevada Prior Authorization List, Pg 84 Original policy |
| 75574 | Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, inc | Nevada Prior Authorization List, Pg 84 Original policy |
| 75580 | Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of the data set from a coronary computed tomography angiography, wit | Nevada Prior Authorization List, Pg 84 Original policy |
| 75635 | Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast materi | Nevada Prior Authorization List, Pg 84 Original policy |
| 76120 | Cineradiography/Videoradiology, Except Where Specifically Included | Nevada Prior Authorization List, Pg 84 Original policy |
| 76376 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under co | Nevada Prior Authorization List, Pg 84 Original policy |
| 76377 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under co | Nevada Prior Authorization List, Pg 84 Original policy |
| 76390 | Mr Spectroscopy | Nevada Prior Authorization List, Pg 84 Original policy |
| 76391 | Magnetic resonance (eg, vibration) elastography | Nevada Prior Authorization List, Pg 84 Original policy |
| 76873 | Echography, Transrectal; Prostate Volume Study, Brachytherapy Planning | Nevada Prior Authorization List, Pg 84 Original policy |
| 76965 | Us Guided, Interstitial Radioelement Application | Nevada Prior Authorization List, Pg 84 Original policy |
| 77046 | Magnetic resonance imaging, breast, without contrast material; unilateral | Nevada Prior Authorization List, Pg 84 Original policy |
| 77047 | Magnetic resonance imaging, breast, without contrast material; bilateral | Nevada Prior Authorization List, Pg 84 Original policy |
| 77048 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokin | Nevada Prior Authorization List, Pg 84 Original policy |
| 77049 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokin | Nevada Prior Authorization List, Pg 84 Original policy |
| 77078 | Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) | Nevada Prior Authorization List, Pg 84 Original policy |
| 77083 | Radiographic absorptiometry (eg, photodensitometry, radiogrammetry), 1 or more sites | Nevada Prior Authorization List, Pg 84 Original policy |
| 77084 | Magnetic resonance (eg, proton) imaging, bone marrow blood supply | Nevada Prior Authorization List, Pg 84 Original policy |
| 77295 | 3-dimensional radiotherapy plan, including dose-volume histograms | Nevada Prior Authorization List, Pg 84 Original policy |
| 77301 | Intensity Modulated Radiotherapy Plan W/Dose Volume Histograms | Nevada Prior Authorization List, Pg 84 Original policy |
| 77316 | Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s) | Nevada Prior Authorization List, Pg 84 Original policy |
| 77317 | Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation( | Nevada Prior Authorization List, Pg 84 Original policy |
| 77318 | Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) | Nevada Prior Authorization List, Pg 84 Original policy |