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Anthem Blue Cross and Blue Shield Nevada prior authorization, page 6

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

Prior authorization codes
CodeDescriptionSource
21083Impression & Custom Preparation; Palatal Lift ProsthesisNevada Prior Authorization List, Pg 12 Original policy
21086Impression & Custom Preparation; Auricular ProsthesisNevada Prior Authorization List, Pg 12 Original policy
21087Impression & Custom Preparation; Nasal ProsthesisNevada Prior Authorization List, Pg 12 Original policy
21110Application, Interdental Fixation Device, Non-Fx/Dislocation, W/RemovalNevada Prior Authorization List, Pg 12 Original policy
21116Injection Proc, Temporomandibular Joint ArthrographyNevada Prior Authorization List, Pg 12 Original policy
21120Genioplasty; Augmentation (Autograft, Allograft, Prosthetic Matl)Nevada Prior Authorization List, Pg 12 Original policy
21121Genioplasty; Sliding Osteotomy, Single PieceNevada Prior Authorization List, Pg 12 Original policy
21122Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chinNevada Prior Authorization List, Pg 12 Original policy
21123Genioplasty; Sliding, Augmentation W/Interpositional Bone Grafts W/Obtaining AutograftNevada Prior Authorization List, Pg 12 Original policy
21125Augmentation, Mandibular Body/Angle; Prosthetic MatlNevada Prior Authorization List, Pg 12 Original policy
21127Augmentation, Mandibular Body/Angle; W/Bone Graft/Onlay/Interpositional W/Obtaining AutograftNevada Prior Authorization List, Pg 12 Original policy
21137Reduction Forehead; Contouring OnlyNevada Prior Authorization List, Pg 12 Original policy
21138Reduction Forehead; Contouring/Prosthesis/Bone Graft W/Obtaining AutograftNevada Prior Authorization List, Pg 13 Original policy
21139Reduction Forehead; Contouring & Setback, Anterior Frontal Sinus WallNevada Prior Authorization List, Pg 13 Original policy
21141Reconstruction Midface, Lefort I; 1 Piece, W/O Bone GraftNevada Prior Authorization List, Pg 13 Original policy
21142Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graftNevada Prior Authorization List, Pg 13 Original policy
21143Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graftNevada Prior Authorization List, Pg 13 Original policy
21145Reconstruction Midface, Lefort I; 1 Piece, W/Bone GraftsNevada Prior Authorization List, Pg 13 Original policy
21146Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtainingNevada Prior Authorization List, Pg 13 Original policy
21147Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes oNevada Prior Authorization List, Pg 13 Original policy
21150Reconstruction Midface, Lefort Ii; Anterior IntrusionNevada Prior Authorization List, Pg 13 Original policy
21151Reconstruction Midface, Lefort Ii; W/Bone GraftsNevada Prior Authorization List, Pg 13 Original policy
21154Reconstruction Midface, Lefort Iii, W/Bone Grafts; W/O Lefort INevada Prior Authorization List, Pg 13 Original policy
21155Reconstruction Midface, Lefort Iii, W/Bone Grafts; W/Lefort INevada Prior Authorization List, Pg 13 Original policy
21159Reconstruction Midface, Lefort Iii, (Extra/Intracranial), W/Bone Grafts, W/O Lefort INevada Prior Authorization List, Pg 13 Original policy
21160Reconstruction Midface, Lefort Iii, (Extra/Intracranial), W/Bone Grafts, W/Lefort INevada Prior Authorization List, Pg 13 Original policy
21172Reconstruction Superior-Lateral Orbital Rim & Lower ForeheadNevada Prior Authorization List, Pg 13 Original policy
21175Reconstruction, Bifrontal,Superior-Lateral Orbital Rims & Lower ForeheadNevada Prior Authorization List, Pg 13 Original policy
21179Reconstruction, Majority, Forehead & Supraorbital Rims; W/Grafts (Allograft/Prosthetic)Nevada Prior Authorization List, Pg 13 Original policy
21180Reconstruction, Majority, Forehead & Supraorbital Rims; W/AutograftNevada Prior Authorization List, Pg 13 Original policy
21182Reconstruction, Orbit/Forehead/Nasoethmoid, Following Excision, Benign Tumor, Graft < 40 Sq CmNevada Prior Authorization List, Pg 13 Original policy
21183Reconstruction, Orbit/Forehead/Nasoethmiod, Following Excision, Benign Tumor, Graft 40-80 Sq CmNevada Prior Authorization List, Pg 13 Original policy
21184Reconstruction, Orbit/Forehead/Nasoethmoid, Following Excision, Benign Tumor, Graft > 80 Sq CmNevada Prior Authorization List, Pg 13 Original policy
21188Reconstruction, Midface, Osteotomies (Non-Lefort Type), W/Grafts, W/Obtaining AutograftsNevada Prior Authorization List, Pg 13 Original policy
21193Reconstruction, Mandibular Rami, Horizontal, Vertical, "C"/"L" Osteotomy; W/O Bone GraftNevada Prior Authorization List, Pg 13 Original policy
21194Reconstruction, Mandibular Rami, Horizontal, Vertical, "C"/"L" Osteotomy; W/Bone GraftNevada Prior Authorization List, Pg 13 Original policy
21195Reconstruction, Mandibular Rami &/Or Body, Sagittal Split; W/O Int Rigid FixationNevada Prior Authorization List, Pg 14 Original policy
21196Reconstruction, Mandibular Rami &/Or Body, Sagittal Split; W/Int Rigid FixationNevada Prior Authorization List, Pg 14 Original policy
21198Osteotomy, Mandible, SegmentalNevada Prior Authorization List, Pg 14 Original policy
21199Osteotomy, Mandible, Segmental; W/Genioglossus AdvancementNevada Prior Authorization List, Pg 14 Original policy
21206Osteotomy, Maxilla, SegmentalNevada Prior Authorization List, Pg 14 Original policy
21208Osteoplasty, Facial Bones; Augmentation (Autograft, Allograft/Prosthetic Implant)Nevada Prior Authorization List, Pg 14 Original policy
21209Osteoplasty, Facial Bones; ReductionNevada Prior Authorization List, Pg 14 Original policy
21210Graft, Bone; Nasal, Maxillary/Malar Areas (Includes Obtaining Graft)Nevada Prior Authorization List, Pg 14 Original policy
21215Graft, Bone; Mandible (Includes Obtaining Graft)Nevada Prior Authorization List, Pg 14 Original policy
21230Graft; Rib Cartilage, Autogenous, Face/Chin/Nose/Ear (Includes Obtaining Graft)Nevada Prior Authorization List, Pg 14 Original policy
21235Graft; Ear Cartilage, Autogenous, Nose/Ear (Includes Obtaining Graft)Nevada Prior Authorization List, Pg 14 Original policy
21240Arthroplasty, Temporomandibular Joint, W/Wo Autograft (Includes Obtaining Graft)Nevada Prior Authorization List, Pg 14 Original policy
21242Arthroplasty, Temporomandibular Joint, W/AllograftNevada Prior Authorization List, Pg 14 Original policy
21243Arthroplasty, Temporomandibular Joint, W/Prosthetic Joint ReplacementNevada Prior Authorization List, Pg 14 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.

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