Anthem Blue Cross and Blue Shield Nevada prior authorization, page 58
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 |
|---|---|---|
| 0560U | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell- free DNA, whole blood and tumor tissue, baseline assessment for design and construction of a persona | Nevada Prior Authorization List, Pg 127 Original policy |
| 0561U | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell- free DNA, whole blood, subsequent assessment with comparison to initial assessment to evaluate for M | Nevada Prior Authorization List, Pg 127 Original policy |
| 0562U | Oncology (solid tumor), targeted genomic sequence analysis, 33 genes, detection of single-nucleotide variants (SNVs), insertions and deletions, copy- number amplifications, and | Nevada Prior Authorization List, Pg 127 Original policy |
| 0563T | Evacuation of meibomian glands, using heat delivered through wearable, open- eye eyelid treatment devices and manual gland expression, bilateral | Nevada Prior Authorization List, Pg 128 Original policy |
| 0565T | Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation | Nevada Prior Authorization List, Pg 128 Original policy |
| 0565U | Oncology (hepatocellular carcinoma), next-generation sequencing methylation pattern assay to detect 6626 epigenetic alterations, cell-free DNA, plasma, algorithm reported as c | Nevada Prior Authorization List, Pg 128 Original policy |
| 0566T | Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound gu | Nevada Prior Authorization List, Pg 128 Original policy |
| 0566U | Oncology (lung), qPCR-based analysis of 13 differentially methylated regions (CCDC181, HOXA7, LRRC8A, MARCHF11, MIR129-2, NCOR2, PANTR1, PRKCB, SLC9A3, TBR1_2, TRAP1, VWC2, ZN | Nevada Prior Authorization List, Pg 128 Original policy |
| 0567U | Rare diseases (constitutional/heritable disorders), whole-genome sequence analysis combination of short and long reads, for single-nucleotide variants, insertions/deletions an | Nevada Prior Authorization List, Pg 128 Original policy |
| 0568U | Neurology (dementia), beta amyloid (AB40, AB42, AB42/40 ratio), tau-protein phosphorylated at residue (eg, pTau217), neurofilament light chain (NfL), and glial fibrillary acid | Nevada Prior Authorization List, Pg 128 Original policy |
| 0569T | Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis | Nevada Prior Authorization List, Pg 128 Original policy |
| 0569U | Oncology (solid tumor), next-generation sequencing analysis of tumor methylation markers (>20000 differentially methylated regions) present in cell- free circulating tumor DNA | Nevada Prior Authorization List, Pg 128 Original policy |
| 0571U | Oncology (solid tumor), DNA (80 genes) and RNA (10 genes), by next-generation sequencing, plasma, including single-nucleotide variants, insertions/deletions, copy-number alter | Nevada Prior Authorization List, Pg 128 Original policy |
| 0580T | Removal of substernal implantable defibrillator pulse generator only | Nevada Prior Authorization List, Pg 128 Original policy |
| 0581T | Ablation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging guidance when performed, unilateral | Nevada Prior Authorization List, Pg 128 Original policy |
| 0584T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when perf | Nevada Prior Authorization List, Pg 128 Original policy |
| 0585T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when perf | Nevada Prior Authorization List, Pg 128 Original policy |
| 0586T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when perf | Nevada Prior Authorization List, Pg 128 Original policy |
| 0587T | Percutaneous implantation or replacement of integrated single device neurostimulation system for bladder dysfunction including electrode array and receiver or pulse generator | Nevada Prior Authorization List, Pg 128 Original policy |
| 0588T | Revision or removal of percutaneously placed integrated single device neurostimulation system for bladder dysfunction including electrode array and receiver or pulse generator | Nevada Prior Authorization List, Pg 128 Original policy |
| 0589U | Perfluoroalkyl substances (PFAS) (eg, perfluorooctanoic acid, perfluorooctane sulfonic acid), 24 PFAS compounds by high-performance liquid chromatography with tandem mass spec | Nevada Prior Authorization List, Pg 128 Original policy |
| 0596T | Temporary female intraurethral valve-pump (ie, voiding prosthesis); initial insertion, including urethral measurement | Nevada Prior Authorization List, Pg 128 Original policy |
| 0597T | Temporary female intraurethral valve-pump (ie, voiding prosthesis); replacement | Nevada Prior Authorization List, Pg 128 Original policy |
| 0600T | Ablation, irreversible electroporation; 1 or more tumors per organ, other than liver or prostate, including imaging guidance, when performed, percutaneous | Nevada Prior Authorization List, Pg 128 Original policy |
| 0601T | Ablation, irreversible electroporation; 1 or more tumors per organ, including fluoroscopic and ultrasound guidance, when performed, open | Nevada Prior Authorization List, Pg 128 Original policy |
| 0607T | Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration | Nevada Prior Authorization List, Pg 129 Original policy |
| 0608T | Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration | Nevada Prior Authorization List, Pg 129 Original policy |
| 0615T | Automated analysis of binocular eye movements without spatial calibration, including disconjugacy, saccades, and pupillary dynamics for the assessment of concussion, with inte | Nevada Prior Authorization List, Pg 129 Original policy |
| 0620T | Endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or | Nevada Prior Authorization List, Pg 129 Original policy |
| 0627T | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first le | Nevada Prior Authorization List, Pg 129 Original policy |
| 0629T | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level | Nevada Prior Authorization List, Pg 129 Original policy |
| 0633T | Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast material | Nevada Prior Authorization List, Pg 129 Original policy |
| 0634T | Computed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s) | Nevada Prior Authorization List, Pg 129 Original policy |
| 0635T | Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s) | Nevada Prior Authorization List, Pg 129 Original policy |
| 0636T | Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s) | Nevada Prior Authorization List, Pg 129 Original policy |
| 0637T | Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s) | Nevada Prior Authorization List, Pg 129 Original policy |
| 0638T | Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s) | Nevada Prior Authorization List, Pg 129 Original policy |
| 0646T | Transcatheter tricuspid valve implantation/replacement (TTVI) with pro | Nevada Prior Authorization List, Pg 129 Original policy |
| 0648T | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmissio | Nevada Prior Authorization List, Pg 129 Original policy |
| 0652T | Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, includin | Nevada Prior Authorization List, Pg 129 Original policy |
| 0653T | Esophagogastroduodenoscopy, flexible, transnasal; with biopsy, single | Nevada Prior Authorization List, Pg 129 Original policy |
| 0654T | Esophagogastroduodenoscopy, flexible, transnasal; with insertion of in | Nevada Prior Authorization List, Pg 129 Original policy |
| 0655T | Transperineal focal laser ablation of malignant prostate tissue, inclu | Nevada Prior Authorization List, Pg 129 Original policy |
| 0658T | Electrical impedance spectroscopy of 1 or more skin lesions for automa | Nevada Prior Authorization List, Pg 129 Original policy |
| 0659T | Transcatheter intracoronary infusion of supersaturated oxygen in conju | Nevada Prior Authorization List, Pg 129 Original policy |
| 0664T | Donor hysterectomy (including cold preservation); open, from cadaver d | Nevada Prior Authorization List, Pg 129 Original policy |
| 0665T | Donor hysterectomy (including cold preservation); open, from living do | Nevada Prior Authorization List, Pg 129 Original policy |
| 0666T | Donor hysterectomy (including cold preservation); laparoscopic or robo | Nevada Prior Authorization List, Pg 129 Original policy |
| 0667T | Donor hysterectomy (including cold preservation); recipient uterus all | Nevada Prior Authorization List, Pg 130 Original policy |
| 0668T | Backbench standard preparation of cadaver or living donor uterine allo | Nevada Prior Authorization List, Pg 130 Original policy |