Anthem Blue Cross and Blue Shield Nevada prior authorization, page 51
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 |
|---|---|---|
| 0101U | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel utilizing a | Nevada Prior Authorization List, Pg 111 Original policy |
| 0102T | Extracorporeal shock wave performed by a physician, requiring anesthesia other than local, and involving the lateral humeral epicondyle | Nevada Prior Authorization List, Pg 111 Original policy |
| 0102U | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing | Nevada Prior Authorization List, Pg 112 Original policy |
| 0103U | Hereditary ovarian cancer (eg, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and arr | Nevada Prior Authorization List, Pg 112 Original policy |
| 0105U | Nephrology (chronic kidney disease), multiplex electrochemiluminescent immunoassay (ECLIA) of tumor necrosis factor receptor 1A, receptor superfamily 2 (TNFR1, TNFR2), and kid | Nevada Prior Authorization List, Pg 112 Original policy |
| 0106T | QST TST-EXT; TOUCH PRESS LG DIAM SENSATION | Nevada Prior Authorization List, Pg 112 Original policy |
| 0107T | QST TST-EXT; VIBRATION LG DIAM FIBER SENSATION | Nevada Prior Authorization List, Pg 112 Original policy |
| 0108T | QST-EXT; COOL SM NRV FIBR SENSATION&HYPERALGESIA | Nevada Prior Authorization List, Pg 112 Original policy |
| 0108U | Gastroenterology (Barrett's esophagus), whole slide-digital imaging, including morphometric analysis, computer-assisted quantitative immunolableing of 9 protein biomarkers (p1 | Nevada Prior Authorization List, Pg 112 Original policy |
| 0109T | QST-EXT;HEAT-PAIN SM NRV FIBR SENSATN&HYPRALGSIA | Nevada Prior Authorization List, Pg 112 Original policy |
| 0110T | QST TST-EXT; OTHER STIMULI ASSESS SENSATION | Nevada Prior Authorization List, Pg 112 Original policy |
| 0111U | Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis utilizing formalin-fixed paraffin- embedded tissue | Nevada Prior Authorization List, Pg 112 Original policy |
| 0112U | Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug-resistance gene | Nevada Prior Authorization List, Pg 112 Original policy |
| 0113U | Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence- based detection, algorith | Nevada Prior Authorization List, Pg 112 Original policy |
| 0117U | Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5- hydroxyindoleacetic acid, hydroxy | Nevada Prior Authorization List, Pg 112 Original policy |
| 0118U | Transplantation medicine, quantification of donor-derived cell-free DNA using whole genome next-generation sequencing, plasma, reported as percentage of donor-derived cell-fre | Nevada Prior Authorization List, Pg 112 Original policy |
| 0120U | Oncology (B-cell lymphoma classification), mRNA, gene expression profiling by fluorescent probe hybridization of 58 genes (45 content and 13 housekeeping genes), formalin-fixe | Nevada Prior Authorization List, Pg 112 Original policy |
| 0129U | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and deletion/dup | Nevada Prior Authorization List, Pg 112 Original policy |
| 0130U | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC | Nevada Prior Authorization List, Pg 112 Original policy |
| 0134U | Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) | Nevada Prior Authorization List, Pg 112 Original policy |
| 0136U | ATM (ataxia telangiectasia mutated) (eg, ataxia telangiectasia) mRNA sequence analysis (List separately in addition to code for primary procedure) | Nevada Prior Authorization List, Pg 112 Original policy |
| 0138U | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) mRNA sequence analysis (List separately in addition to co | Nevada Prior Authorization List, Pg 112 Original policy |
| 0152U | Infectious disease (bacteria, fungi, parasites, and DNA viruses), microbial cell- free DNA, plasma, untargeted next-generation sequencing, report for significant positive patho | Nevada Prior Authorization List, Pg 112 Original policy |
| 0153U | Oncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a tripl | Nevada Prior Authorization List, Pg 112 Original policy |
| 0154U | Oncology (urothelial cancer), RNA, analysis by real-time RT-PCR of the FGFR3 (fibroblast growth factor receptor 3) gene analysis (ie, p.R248C [c.742C>T], p.S249C [c.746C>G], p | Nevada Prior Authorization List, Pg 112 Original policy |
| 0155U | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha) (eg, breast cancer) gene analysis (ie, p.C420R, p.E542K, p.E545 | Nevada Prior Authorization List, Pg 113 Original policy |
| 0156U | Copy number (eg, intellectual disability, dysmorphology), sequence analysis | Nevada Prior Authorization List, Pg 113 Original policy |
| 0163T | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar (Li | Nevada Prior Authorization List, Pg 113 Original policy |
| 0164T | Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separ | Nevada Prior Authorization List, Pg 113 Original policy |
| 0164U | Gastroenterology (irritable bowel syndrome [IBS]), immunoassay for anti-CdtB and anti-vinculin antibodies, utilizing plasma, algorithm for elevated or not elevated qualitative | Nevada Prior Authorization List, Pg 113 Original policy |
| 0165T | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspa | Nevada Prior Authorization List, Pg 113 Original policy |
| 0166U | Liver disease, 10 biochemical assays (+2-macroglobulin, haptoglobin, apolipoprotein A1, bilirubin, GGT, ALT, AST, triglycerides, cholesterol, fasting glucose) and biometric a | Nevada Prior Authorization List, Pg 113 Original policy |
| 0169U | NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) (eg, drug metabolism) gene analysis, common variants | Nevada Prior Authorization List, Pg 113 Original policy |
| 0170U | Neurology (autism spectrum disorder [ASD]), RNA, next-generation sequencing, saliva, algorithmic analysis, and results reported as predictive probability of ASD diagnosis | Nevada Prior Authorization List, Pg 113 Original policy |
| 0171U | Targeted genomic sequence analysis panel, acute myeloid leukemia, myelodysplastic syndrome, and myeloproliferative neoplasms, DNA analysis, 23 genes, interrogation for sequenc | Nevada Prior Authorization List, Pg 113 Original policy |
| 0172U | Oncology (solid tumor as indicated by the label), somatic mutation analysis of BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) and analysis of homol | Nevada Prior Authorization List, Pg 113 Original policy |
| 0173U | Psychiatry (ie, depression, anxiety), genomic analysis panel, includes variant analysis of 14 gene | Nevada Prior Authorization List, Pg 113 Original policy |
| 0174U | Oncology (solid tumor), mass spectrometric 30 protein targets, formalin-fixed paraffin-embedded tissue, prognostic and predictive algorithm reported as likely, unlikely, or un | Nevada Prior Authorization List, Pg 113 Original policy |
| 0175U | Psychiatry (eg, depression, anxiety), genomic analysis panel, variant analysis of 15 genes | Nevada Prior Authorization List, Pg 113 Original policy |
| 0176U | Cytolethal distending toxin B (CdtB) and vinculin IgG antibodies by immunoassay (ie, ELISA) | Nevada Prior Authorization List, Pg 113 Original policy |
| 0177U | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha) gene analysis of 11 gene variants utilizing plasma, reported as | Nevada Prior Authorization List, Pg 113 Original policy |
| 0179U | Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior kno | Nevada Prior Authorization List, Pg 113 Original policy |
| 0186T | Suprachoroidal delivery of pharmacologic agent (does not include supply of medication) | Nevada Prior Authorization List, Pg 113 Original policy |
| 0191T | Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular meshwork | Nevada Prior Authorization List, Pg 113 Original policy |
| 0192T | Insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach | Nevada Prior Authorization List, Pg 113 Original policy |
| 0200T | Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles | Nevada Prior Authorization List, Pg 113 Original policy |
| 0201T | Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles | Nevada Prior Authorization List, Pg 113 Original policy |
| 0202T | Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foramin | Nevada Prior Authorization List, Pg 113 Original policy |
| 0203U | Autoimmune (inflammatory bowel disease), mRNA, gene expression profiling by quantitative RT-PCR, 17 genes (15 target and 2 reference genes), whole blood, reported as a continu | Nevada Prior Authorization List, Pg 113 Original policy |
| 0205U | Ophthalmology (age-related macular degeneration), analysis of 3 gene variants (2 CFH gene, 1 ARMS2 gene), using PCR and MALDI-TOF, buccal swab, reported as positive or negativ | Nevada Prior Authorization List, Pg 114 Original policy |