Anthem Blue Cross and Blue Shield Nevada prior authorization, page 5
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 |
|---|---|---|
| 19367 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap | Nevada Prior Authorization List, Pg 10 Original policy |
| 19368 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging) | Nevada Prior Authorization List, Pg 10 Original policy |
| 19369 | Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap | Nevada Prior Authorization List, Pg 10 Original policy |
| 19380 | Revision of reconstructed breast (eg, significant removal of tissue, re- advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision comb | Nevada Prior Authorization List, Pg 10 Original policy |
| 19396 | Preparation, Moulage, Custom Breast Implant | Nevada Prior Authorization List, Pg 10 Original policy |
| 20220 | Bx, Bone, Trocar/Needle; Superficial | Nevada Prior Authorization List, Pg 10 Original policy |
| 20225 | Bx, Bone, Trocar/Needle; Deep | Nevada Prior Authorization List, Pg 10 Original policy |
| 20240 | Biopsy, bone, open; superficial (eg, sternum, spinous process, rib, patella, olecranon process, calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx) | Nevada Prior Authorization List, Pg 10 Original policy |
| 20245 | Biopsy, bone, open; deep (eg, humeral shaft, ischium, femoral shaft) | Nevada Prior Authorization List, Pg 10 Original policy |
| 20520 | Removal, Fb In Muscle/Tendon Sheath; Simple | Nevada Prior Authorization List, Pg 10 Original policy |
| 20525 | Removal, Fb In Muscle/Tendon Sheath; Deep/Complicated | Nevada Prior Authorization List, Pg 10 Original policy |
| 20526 | Injection, Therapeutic, Carpal Canal | Nevada Prior Authorization List, Pg 10 Original policy |
| 20551 | Injection(S); Tendon Origin/Insertion | Nevada Prior Authorization List, Pg 10 Original policy |
| 20552 | Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) | Nevada Prior Authorization List, Pg 10 Original policy |
| 20553 | Injection(s); single or multiple trigger point(s), 3 or more muscle(s) | Nevada Prior Authorization List, Pg 11 Original policy |
| 20555 | Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (a | Nevada Prior Authorization List, Pg 11 Original policy |
| 20560 | Needle insertion(s) without injection(s); 1 or 2 muscle(s) | Nevada Prior Authorization List, Pg 11 Original policy |
| 20561 | Needle insertion(s) without injection(s); 3 or more muscles | Nevada Prior Authorization List, Pg 11 Original policy |
| 20600 | Arthrocentesis, Aspiration &/Or Injection; Small Joint/Bursa | Nevada Prior Authorization List, Pg 11 Original policy |
| 20604 | Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting | Nevada Prior Authorization List, Pg 11 Original policy |
| 20605 | Arthrocentesis, Aspiration &/Or Injection; Intermediate Joint/Bursa | Nevada Prior Authorization List, Pg 11 Original policy |
| 20606 | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound gu | Nevada Prior Authorization List, Pg 11 Original policy |
| 20611 | Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reportin | Nevada Prior Authorization List, Pg 11 Original policy |
| 20612 | Aspiration &/Or Injection, Ganglion Cyst(S) Any Location | Nevada Prior Authorization List, Pg 11 Original policy |
| 20680 | Removal, Implant; Deep | Nevada Prior Authorization List, Pg 11 Original policy |
| 20930 | Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) | Nevada Prior Authorization List, Pg 11 Original policy |
| 20931 | Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) | Nevada Prior Authorization List, Pg 11 Original policy |
| 20932 | Allograft, includes templating, cutting, placement and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone (List separately in a | Nevada Prior Authorization List, Pg 11 Original policy |
| 20933 | Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (ie, hemicylindrical) (List separately in addition | Nevada Prior Authorization List, Pg 11 Original policy |
| 20934 | Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (ie, cylindrical) (List separately in addition to code for prim | Nevada Prior Authorization List, Pg 11 Original policy |
| 20936 | Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments | Nevada Prior Authorization List, Pg 11 Original policy |
| 20937 | Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) | Nevada Prior Authorization List, Pg 11 Original policy |
| 20938 | Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separat | Nevada Prior Authorization List, Pg 11 Original policy |
| 20939 | Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) | Nevada Prior Authorization List, Pg 11 Original policy |
| 20974 | Electrical Stimulation To Aid Bone Healing; Noninvasive (Nonoperative) | Nevada Prior Authorization List, Pg 11 Original policy |
| 20979 | Low Intensity Ultrasound Stimulation To Aid Bone Healing; Noninvasive | Nevada Prior Authorization List, Pg 12 Original policy |
| 20982 | Ablation, Bone Tumor(s) Radiofrequency, Percutaneous, Including Computed Tomographic Guidance | Nevada Prior Authorization List, Pg 12 Original policy |
| 20983 | Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, includin | Nevada Prior Authorization List, Pg 12 Original policy |
| 21010 | Arthrotomy, Temporomandibular Joint | Nevada Prior Authorization List, Pg 12 Original policy |
| 21011 | Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm | Nevada Prior Authorization List, Pg 12 Original policy |
| 21012 | Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greater | Nevada Prior Authorization List, Pg 12 Original policy |
| 21013 | Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 2 cm | Nevada Prior Authorization List, Pg 12 Original policy |
| 21014 | Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); 2 cm or greater | Nevada Prior Authorization List, Pg 12 Original policy |
| 21029 | Removal By Contouring, Benign Tumor, Facial Bone | Nevada Prior Authorization List, Pg 12 Original policy |
| 21030 | Excision, Benign Tumor/Cyst Maxilla/Zygoma, Enucleation And Curettage | Nevada Prior Authorization List, Pg 12 Original policy |
| 21031 | Excision, Torus Mandibularis | Nevada Prior Authorization List, Pg 12 Original policy |
| 21040 | Excision, Benign Tumor/Cyst, Mandible; Enucleation &/Or Curettage | Nevada Prior Authorization List, Pg 12 Original policy |
| 21050 | Condylectomy, Temporomandibular Joint (Sep Proc) | Nevada Prior Authorization List, Pg 12 Original policy |
| 21060 | Meniscectomy, Partial/Complete, Temporomandibular Joint (Sep Proc) | Nevada Prior Authorization List, Pg 12 Original policy |
| 21073 | Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e., general or monitor | Nevada Prior Authorization List, Pg 12 Original policy |