Anthem Blue Cross and Blue Shield Nevada prior authorization, page 49
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 |
|---|---|---|
| 97112 | Therapeutic Proc, 1+ Areas, Each 15 Min; Neuromuscular Reeducation | Nevada Prior Authorization List, Pg 107 Original policy |
| 97113 | Therapeutic Proc, 1+ Areas, Each 15 Min; Aquatic Therapy W/Exercises | Nevada Prior Authorization List, Pg 107 Original policy |
| 97116 | Therapeutic Proc, 1+ Areas, Each 15 Min; Gait Training (W/Stair Climbing) | Nevada Prior Authorization List, Pg 107 Original policy |
| 97124 | Therapeutic Proc, 1+ Areas, Each 15 Min; Massage | Nevada Prior Authorization List, Pg 107 Original policy |
| 97129 | Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensato | Nevada Prior Authorization List, Pg 107 Original policy |
| 97130 | Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensato | Nevada Prior Authorization List, Pg 107 Original policy |
| 97140 | Manual Therapy Techniques, 1+ Regions, Each 15 Min | Nevada Prior Authorization List, Pg 107 Original policy |
| 97150 | Therapeutic Proc(S), Group, (2+ Individuals) | Nevada Prior Authorization List, Pg 107 Original policy |
| 97161 | Physical therapy evaluation; low complexity, requiring components | Nevada Prior Authorization List, Pg 107 Original policy |
| 97162 | Physical therapy evaluation; moderate complexity requiring components | Nevada Prior Authorization List, Pg 107 Original policy |
| 97163 | Physical therapy evaluation; high complexity requiring components | Nevada Prior Authorization List, Pg 107 Original policy |
| 97164 | Reevaluation of physical therapy established plan of care requiring components | Nevada Prior Authorization List, Pg 107 Original policy |
| 97165 | Occupational therapy evaluation; low complexity requiring components | Nevada Prior Authorization List, Pg 107 Original policy |
| 97166 | Occupational therapy evaluation; moderate complexity requiring components | Nevada Prior Authorization List, Pg 107 Original policy |
| 97167 | Occupational therapy evaluation; high complexity requiring components | Nevada Prior Authorization List, Pg 107 Original policy |
| 97168 | Reevaluation of occupational therapy care/established plan of care requiring components | Nevada Prior Authorization List, Pg 108 Original policy |
| 97530 | Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes | Nevada Prior Authorization List, Pg 108 Original policy |
| 97533 | Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes | Nevada Prior Authorization List, Pg 108 Original policy |
| 97535 | Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive t | Nevada Prior Authorization List, Pg 108 Original policy |
| 97537 | Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis | Nevada Prior Authorization List, Pg 108 Original policy |
| 97542 | Wheelchair management (eg, assessment, fitting, training), each 15 minutes | Nevada Prior Authorization List, Pg 108 Original policy |
| 97545 | Work Hardening/Conditioning; Initial 2 Hours | Nevada Prior Authorization List, Pg 108 Original policy |
| 97546 | Work Hardening/Conditioning; Add'l Hr | Nevada Prior Authorization List, Pg 108 Original policy |
| 97610 | Low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day | Nevada Prior Authorization List, Pg 108 Original policy |
| 97750 | Physical Performance Test, W/Written Report, Each 15 Min | Nevada Prior Authorization List, Pg 108 Original policy |
| 97755 | Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct on | Nevada Prior Authorization List, Pg 108 Original policy |
| 97760 | Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s | Nevada Prior Authorization List, Pg 108 Original policy |
| 97761 | Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes | Nevada Prior Authorization List, Pg 108 Original policy |
| 97763 | Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes | Nevada Prior Authorization List, Pg 108 Original policy |
| 99151 | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation suppor | Nevada Prior Authorization List, Pg 108 Original policy |
| 99152 | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation suppor | Nevada Prior Authorization List, Pg 108 Original policy |
| 99155 | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing | Nevada Prior Authorization List, Pg 108 Original policy |
| 99156 | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing | Nevada Prior Authorization List, Pg 109 Original policy |
| 99183 | Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session | Nevada Prior Authorization List, Pg 109 Original policy |
| 0001U | Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported | Nevada Prior Authorization List, Pg 109 Original policy |
| 0002M | Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A- 1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizi | Nevada Prior Authorization List, Pg 109 Original policy |
| 0003M | Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A- 1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizi | Nevada Prior Authorization List, Pg 109 Original policy |
| 0005U | Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score | Nevada Prior Authorization List, Pg 109 Original policy |
| 0006M | Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk clas | Nevada Prior Authorization List, Pg 109 Original policy |
| 0007M | Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor d | Nevada Prior Authorization List, Pg 109 Original policy |
| 0007U | Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in | Nevada Prior Authorization List, Pg 109 Original policy |
| 0011M | Oncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and urine, algorithms to predict high-grade pr | Nevada Prior Authorization List, Pg 109 Original policy |
| 0012M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing urine, algorithm rep | Nevada Prior Authorization List, Pg 109 Original policy |
| 0013M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm re | Nevada Prior Authorization List, Pg 109 Original policy |
| 0016M | Oncology (bladder), mRNA, microarray gene expression profiling of 219 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (lumina | Nevada Prior Authorization List, Pg 109 Original policy |
| 0016U | Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not de | Nevada Prior Authorization List, Pg 109 Original policy |
| 0017M | Oncology (diffuse large B-cell lymphoma [DLBCL]), mRNA, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffin- embedded tissue, algo | Nevada Prior Authorization List, Pg 109 Original policy |
| 0017U | Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or | Nevada Prior Authorization List, Pg 109 Original policy |
| 0018M | Transplantation medicine (allograft rejection, renal), measurement of donor and third-party-induced CD154+T-cytotoxic memory cells, utilizing whole peripheral blood, algorithm | Nevada Prior Authorization List, Pg 109 Original policy |
| 0018U | Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to | Nevada Prior Authorization List, Pg 109 Original policy |