Anthem Blue Cross and Blue Shield Nevada prior authorization, page 39
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 |
|---|---|---|
| 77338 | Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT | Nevada Prior Authorization List, Pg 85 Original policy |
| 77370 | Special Medical Radiation Physics Consultation | Nevada Prior Authorization List, Pg 85 Original policy |
| 77371 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consist | Nevada Prior Authorization List, Pg 85 Original policy |
| 77372 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consist | Nevada Prior Authorization List, Pg 85 Original policy |
| 77373 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, en | Nevada Prior Authorization List, Pg 85 Original policy |
| 77387 | Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed | Nevada Prior Authorization List, Pg 85 Original policy |
| 77402 | Radiation treatment delivery; Level 1 (eg, single-electron field, multiple- electron fields, or 2D photons), including imaging guidance, when performed | Nevada Prior Authorization List, Pg 85 Original policy |
| 77407 | Radiation treatment delivery; Level 2, single-isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed | Nevada Prior Authorization List, Pg 85 Original policy |
| 77412 | Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (eg, 2D, 3D, or IMRT) or a single-isocenter photon therapy (eg, 3D or IMRT) with active motion m | Nevada Prior Authorization List, Pg 85 Original policy |
| 77423 | High energy neutron radiation treatment delivery, 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) | Nevada Prior Authorization List, Pg 85 Original policy |
| 77424 | Intraoperative Radiation Treatment Delivery, X-Ray, Single Treatment Session | Nevada Prior Authorization List, Pg 85 Original policy |
| 77425 | Intraoperative Radiation Treatment Delivery, Electrons, Single Treatment Session | Nevada Prior Authorization List, Pg 85 Original policy |
| 77432 | Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) | Nevada Prior Authorization List, Pg 85 Original policy |
| 77435 | Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image g | Nevada Prior Authorization List, Pg 85 Original policy |
| 77469 | Intraoperative Radiation Treatment Management | Nevada Prior Authorization List, Pg 85 Original policy |
| 77470 | Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation) | Nevada Prior Authorization List, Pg 85 Original policy |
| 77520 | Proton Treatment Delivery; Simple W/O Compensation | Nevada Prior Authorization List, Pg 85 Original policy |
| 77522 | Proton Treatment Delivery; Simple W/Compensation | Nevada Prior Authorization List, Pg 85 Original policy |
| 77523 | Proton Treatment Delivery; Intermediate | Nevada Prior Authorization List, Pg 85 Original policy |
| 77525 | Proton Treatment Delivery; Complex | Nevada Prior Authorization List, Pg 85 Original policy |
| 77761 | Intracavitary Radiation Source Application; Simple | Nevada Prior Authorization List, Pg 85 Original policy |
| 77762 | Intracavitary Radiation Source Application; Intermediate | Nevada Prior Authorization List, Pg 86 Original policy |
| 77763 | Intracavitary Radiation Source Application; Complex | Nevada Prior Authorization List, Pg 86 Original policy |
| 77767 | Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel | Nevada Prior Authorization List, Pg 86 Original policy |
| 77768 | Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or mu | Nevada Prior Authorization List, Pg 86 Original policy |
| 77770 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel | Nevada Prior Authorization List, Pg 86 Original policy |
| 77771 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels | Nevada Prior Authorization List, Pg 86 Original policy |
| 77772 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels | Nevada Prior Authorization List, Pg 86 Original policy |
| 77778 | Interstitial Radioelement Application; Complex | Nevada Prior Authorization List, Pg 86 Original policy |
| 77790 | Supervision, Handling, Loading, Radiation Source | Nevada Prior Authorization List, Pg 86 Original policy |
| 78429 | Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single s | Nevada Prior Authorization List, Pg 86 Original policy |
| 78430 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at re | Nevada Prior Authorization List, Pg 86 Original policy |
| 78431 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at | Nevada Prior Authorization List, Pg 86 Original policy |
| 78432 | Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], w | Nevada Prior Authorization List, Pg 86 Original policy |
| 78433 | Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], w | Nevada Prior Authorization List, Pg 86 Original policy |
| 78451 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall mo | Nevada Prior Authorization List, Pg 86 Original policy |
| 78452 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall mo | Nevada Prior Authorization List, Pg 86 Original policy |
| 78453 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall mo | Nevada Prior Authorization List, Pg 86 Original policy |
| 78454 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall mo | Nevada Prior Authorization List, Pg 86 Original policy |
| 78459 | Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single s | Nevada Prior Authorization List, Pg 86 Original policy |
| 78466 | Myocardial Imaging, Infarct Avid, Planar; Qualitative/Quantitative | Nevada Prior Authorization List, Pg 86 Original policy |
| 78468 | Myocardial Imaging, Infarct Avid, Planar; W/Ejection Fraction, 1st Pass Technique | Nevada Prior Authorization List, Pg 86 Original policy |
| 78469 | Myocardial Imaging, Infarct Avid, Planar; Tomographic Spect W/Wo Quantification | Nevada Prior Authorization List, Pg 86 Original policy |
| 78472 | Cardiac Blood Pool Imaging, Gated Equilibrium; Planar, Single Study, Rest/Stress | Nevada Prior Authorization List, Pg 86 Original policy |
| 78473 | Cardiac Blood Pool Imaging, Gated Equilibrium; Planar, Multiple Studies, Rest/Stress | Nevada Prior Authorization List, Pg 86 Original policy |
| 78481 | Cardiac Blood Pool Imaging, Planar, 1st Pass; Single Study & Ejection Fraction W/Wo Quantification | Nevada Prior Authorization List, Pg 86 Original policy |
| 78483 | Cardiac Blood Pool Imaging, Planar, 1st Pass; Mult Studies, Rest & Stress & Eject Fractn W/Wo Quant | Nevada Prior Authorization List, Pg 87 Original policy |
| 78491 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at re | Nevada Prior Authorization List, Pg 87 Original policy |
| 78492 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at | Nevada Prior Authorization List, Pg 87 Original policy |
| 78494 | Cardiac Blood Pool Imaging, Gated Equilibrium, Rest, Spect, & Ejection Fraction W/Wo Quantification | Nevada Prior Authorization List, Pg 87 Original policy |