Anthem Blue Cross and Blue Shield Nevada prior authorization, page 40
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 |
|---|---|---|
| 78608 | Brain Imaging, Positron Emission Tomography (Pet); Metabolic Evaluation | Nevada Prior Authorization List, Pg 87 Original policy |
| 78609 | Brain Imaging, Positron Emission Tomography (Pet); Perfusion Evaluation | Nevada Prior Authorization List, Pg 87 Original policy |
| 78811 | Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck) | Nevada Prior Authorization List, Pg 87 Original policy |
| 78812 | Positron emission tomography (PET) imaging; skull base to mid-thigh | Nevada Prior Authorization List, Pg 87 Original policy |
| 78813 | Positron emission tomography (PET) imaging; whole body | Nevada Prior Authorization List, Pg 87 Original policy |
| 78814 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and an | Nevada Prior Authorization List, Pg 87 Original policy |
| 78815 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and an | Nevada Prior Authorization List, Pg 87 Original policy |
| 78816 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and an | Nevada Prior Authorization List, Pg 87 Original policy |
| 79101 | Radiopharmaceutical Therapy, By Intravenous Administration | Nevada Prior Authorization List, Pg 87 Original policy |
| 79403 | Radiopharmaceutical Therapy, Radiolabeled Monoclonal Antibody By Intravenous Infusion | Nevada Prior Authorization List, Pg 87 Original policy |
| 81120 | IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg, glioma), common variants (eg, R132H, R132C) | Nevada Prior Authorization List, Pg 87 Original policy |
| 81121 | IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (eg, glioma), common variants (eg, R140W, R172M) | Nevada Prior Authorization List, Pg 87 Original policy |
| 81161 | DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed | Nevada Prior Authorization List, Pg 87 Original policy |
| 81162 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplicatio | Nevada Prior Authorization List, Pg 87 Original policy |
| 81163 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis | Nevada Prior Authorization List, Pg 87 Original policy |
| 81164 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, de | Nevada Prior Authorization List, Pg 87 Original policy |
| 81165 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis | Nevada Prior Authorization List, Pg 87 Original policy |
| 81166 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) | Nevada Prior Authorization List, Pg 87 Original policy |
| 81167 | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) | Nevada Prior Authorization List, Pg 87 Original policy |
| 81170 | ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (eg, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain | Nevada Prior Authorization List, Pg 87 Original policy |
| 81171 | AFF2 (ALF transcription elongation factor 2 [FMR2]) (eg, fragile X intellectual disability 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 88 Original policy |
| 81172 | AFF2 (ALF transcription elongation factor 2 [FMR2]) (eg, fragile X intellectual disability 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methyla | Nevada Prior Authorization List, Pg 88 Original policy |
| 81173 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence | Nevada Prior Authorization List, Pg 88 Original policy |
| 81174 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant | Nevada Prior Authorization List, Pg 88 Original policy |
| 81175 | ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; fu | Nevada Prior Authorization List, Pg 88 Original policy |
| 81176 | ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; ta | Nevada Prior Authorization List, Pg 88 Original policy |
| 81177 | ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 88 Original policy |
| 81178 | ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 88 Original policy |
| 81179 | ATXN2 (ataxin 2) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 88 Original policy |
| 81180 | ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 88 Original policy |
| 81181 | ATXN7 (ataxin 7) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 88 Original policy |
| 81182 | ATXN8OS (ATXN8 opposite strand [non-protein coding]) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 88 Original policy |
| 81183 | ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 88 Original policy |
| 81184 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 88 Original policy |
| 81185 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence | Nevada Prior Authorization List, Pg 88 Original policy |
| 81186 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant | Nevada Prior Authorization List, Pg 88 Original policy |
| 81187 | CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 88 Original policy |
| 81188 | CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 88 Original policy |
| 81189 | CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence | Nevada Prior Authorization List, Pg 88 Original policy |
| 81190 | CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) | Nevada Prior Authorization List, Pg 88 Original policy |
| 81191 | NTRK1 (neurotrophic receptor tyrosine kinase 1) (eg, solid tumors) translocation analysis | Nevada Prior Authorization List, Pg 88 Original policy |
| 81192 | NTRK2 (neurotrophic receptor tyrosine kinase 2) (eg, solid tumors) translocation analysis | Nevada Prior Authorization List, Pg 88 Original policy |
| 81193 | NTRK3 (neurotrophic receptor tyrosine kinase 3) (eg, solid tumors) translocation analysis | Nevada Prior Authorization List, Pg 88 Original policy |
| 81194 | NTRK (neurotrophic-tropomyosin receptor tyrosine kinase 1, 2, and 3) (eg, solid tumors) translocation analysis | Nevada Prior Authorization List, Pg 88 Original policy |
| 81195 | Cytogenomic analysis, optical genome mapping | Nevada Prior Authorization List, Pg 88 Original policy |
| 81200 | Aspa (Aspartoacylase) (Eg, Canavan Disease) Gene Analysis, Common Variants (Eg, E285A, Y231X) | Nevada Prior Authorization List, Pg 89 Original policy |
| 81201 | APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence | Nevada Prior Authorization List, Pg 89 Original policy |
| 81202 | APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants | Nevada Prior Authorization List, Pg 89 Original policy |
| 81203 | APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants | Nevada Prior Authorization List, Pg 89 Original policy |
| 81204 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; characterization of alleles (eg, expanded size or me | Nevada Prior Authorization List, Pg 89 Original policy |