Anthem Blue Cross and Blue Shield Nevada prior authorization, page 59
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 |
|---|---|---|
| 0669T | Backbench reconstruction of cadaver or living donor uterus allograft p | Nevada Prior Authorization List, Pg 130 Original policy |
| 0670T | Backbench reconstruction of cadaver or living donor uterus allograft p | Nevada Prior Authorization List, Pg 130 Original policy |
| 0671T | Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more | Nevada Prior Authorization List, Pg 130 Original policy |
| 0672T | Endovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence | Nevada Prior Authorization List, Pg 130 Original policy |
| 0673T | Ablation, benign thyroid nodule(s), percutaneous, laser, including imaging guidance | Nevada Prior Authorization List, Pg 130 Original policy |
| 0686T | Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance | Nevada Prior Authorization List, Pg 130 Original policy |
| 0689T | Quantitative ultrasound tissue characterization (non-elastographic), including interpretation and report, obtained without diagnostic ultrasound examination of the same anatom | Nevada Prior Authorization List, Pg 130 Original policy |
| 0692T | Therapeutic ultrafiltration | Nevada Prior Authorization List, Pg 130 Original policy |
| 0700T | Molecular fluorescent imaging of suspicious nevus; first lesion | Nevada Prior Authorization List, Pg 130 Original policy |
| 0701T | Molecular fluorescent imaging of suspicious nevus; each additional lesion (List separately in addition to code for primary procedure) | Nevada Prior Authorization List, Pg 130 Original policy |
| 0707T | Injection(s), bone-substitute material (eg, calcium phosphate) into subchondral bone defect (ie, bone marrow lesion, bone bruise, stress injury, microtrabecular fracture), inc | Nevada Prior Authorization List, Pg 130 Original policy |
| 0717T | Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, i | Nevada Prior Authorization List, Pg 130 Original policy |
| 0718T | Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilate | Nevada Prior Authorization List, Pg 130 Original policy |
| 0736T | Colonic lavage, 35 or more liters of water, gravity-fed, with induced defecation, including insertion of rectal catheter | Nevada Prior Authorization List, Pg 130 Original policy |
| 0738T | Treatment planning for magnetic field induction ablation of malignant prostate tissue, using data from previously performed magnetic resonance imaging (MRI) examination | Nevada Prior Authorization List, Pg 130 Original policy |
| 0739T | Ablation of malignant prostate tissue by magnetic field induction, including all intraprocedural, transperineal needle/catheter placement for nanoparticle installation and int | Nevada Prior Authorization List, Pg 130 Original policy |
| 0745T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image da | Nevada Prior Authorization List, Pg 130 Original policy |
| 0746T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiati | Nevada Prior Authorization List, Pg 130 Original policy |
| 0747T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia | Nevada Prior Authorization List, Pg 130 Original policy |
| 0748T | Injections of stem cell product into perianal perifistular soft tissue, including fistula preparation (eg, removal of setons, fistula curettage, closure of internal openings) | Nevada Prior Authorization List, Pg 130 Original policy |
| 0766T | Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, with identification and marking of the treatment location, including noni | Nevada Prior Authorization List, Pg 130 Original policy |
| 0767T | Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, with identification and marking of the treatment location, including noni | Nevada Prior Authorization List, Pg 130 Original policy |
| 0770T | Virtual reality technology to assist therapy (List separately in addition to code for primary procedure) | Nevada Prior Authorization List, Pg 130 Original policy |
| 0771T | Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic servi | Nevada Prior Authorization List, Pg 131 Original policy |
| 0772T | Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic servi | Nevada Prior Authorization List, Pg 131 Original policy |
| 0773T | Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health ca | Nevada Prior Authorization List, Pg 131 Original policy |
| 0774T | Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health ca | Nevada Prior Authorization List, Pg 131 Original policy |
| 0778T | Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscl | Nevada Prior Authorization List, Pg 131 Original policy |
| 0786T | Insertion or replacement of percutaneous electrode array, sacral, with integrated neurostimulator, including imaging guidance, when performed | Nevada Prior Authorization List, Pg 131 Original policy |
| 0787T | Revision or removal of neurostimulator electrode array, sacral, with integrated neurostimulator | Nevada Prior Authorization List, Pg 131 Original policy |
| 0795T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventric | Nevada Prior Authorization List, Pg 131 Original policy |
| 0796T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventric | Nevada Prior Authorization List, Pg 131 Original policy |
| 0797T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventric | Nevada Prior Authorization List, Pg 131 Original policy |
| 0798T | Transcatheter removal of permanent dual-chamber leadless pacemaker,?including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventricul | Nevada Prior Authorization List, Pg 131 Original policy |
| 0799T | Transcatheter removal of permanent dual-chamber leadless pacemaker,?including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventricul | Nevada Prior Authorization List, Pg 131 Original policy |
| 0800T | Transcatheter removal of permanent dual-chamber leadless pacemaker,?including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventricul | Nevada Prior Authorization List, Pg 131 Original policy |
| 0801T | Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging?guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography | Nevada Prior Authorization List, Pg 131 Original policy |
| 0802T | Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging?guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography | Nevada Prior Authorization List, Pg 131 Original policy |
| 0803T | Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging?guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography | Nevada Prior Authorization List, Pg 131 Original policy |
| 0810T | Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies | Nevada Prior Authorization List, Pg 131 Original policy |
| 0813T | Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of intragastric bariatric balloon | Nevada Prior Authorization List, Pg 131 Original policy |
| 0816T | Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (eg, array or leadless), and pulse generator or receiver, in | Nevada Prior Authorization List, Pg 131 Original policy |
| 0817T | Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (eg, array or leadless), and pulse generator or receiver, in | Nevada Prior Authorization List, Pg 131 Original policy |
| 0818T | Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subcut | Nevada Prior Authorization List, Pg 131 Original policy |
| 0819T | Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subfas | Nevada Prior Authorization List, Pg 131 Original policy |
| 0823T | Transcatheter insertion of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography | Nevada Prior Authorization List, Pg 132 Original policy |
| 0824T | Transcatheter removal of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography an | Nevada Prior Authorization List, Pg 132 Original policy |
| 0825T | Transcatheter removal and replacement of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atria | Nevada Prior Authorization List, Pg 132 Original policy |
| 0861T | Removal of pulse generator for wireless cardiac stimulator for left ventricular pacing; both components (battery and transmitter) | Nevada Prior Authorization List, Pg 132 Original policy |
| 0862T | Relocation of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; battery component only | Nevada Prior Authorization List, Pg 132 Original policy |