Anthem Blue Cross and Blue Shield Nevada prior authorization, page 60
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 |
|---|---|---|
| 0863T | Relocation of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; transmitter component only | Nevada Prior Authorization List, Pg 132 Original policy |
| 0864T | Low-intensity extracorporeal shock wave therapy involving corpus cavernosum, low energy | Nevada Prior Authorization List, Pg 132 Original policy |
| 0888T | Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including imaging guidance | Nevada Prior Authorization List, Pg 132 Original policy |
| 0894T | Cannulation of the liver allograft in preparation for connection to the normothermic perfusion device and decannulation of the liver allograft following normothermic perfusion | Nevada Prior Authorization List, Pg 132 Original policy |
| 0895T | Connection of liver allograft to normothermic machine perfusion device, hemostasis control; initial 4 hours of monitoring time, including hourly physiological and laboratory a | Nevada Prior Authorization List, Pg 132 Original policy |
| 0908T | Open implantation of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed | Nevada Prior Authorization List, Pg 132 Original policy |
| 0909T | Replacement of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed | Nevada Prior Authorization List, Pg 132 Original policy |
| 0910T | Removal of integrated neurostimulation system, vagus nerve | Nevada Prior Authorization List, Pg 132 Original policy |
| 0911T | Electronic analysis of implanted integrated neurostimulation system, vagus nerve; without programming by physician or other qualified health care professional | Nevada Prior Authorization List, Pg 132 Original policy |
| 0912T | Electronic analysis of implanted integrated neurostimulation system, vagus nerve; with simple programming by physician or other qualified health care professional | Nevada Prior Authorization List, Pg 132 Original policy |
| 0913T | Percutaneous transcatheter therapeutic drug delivery by intracoronary drugdelivery balloon (eg, drug-coated, drug-eluting), including mechanical dilation by nondrug-delivery | Nevada Prior Authorization List, Pg 132 Original policy |
| 0915T | Insertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and ther | Nevada Prior Authorization List, Pg 132 Original policy |
| 0916T | Insertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and ther | Nevada Prior Authorization List, Pg 132 Original policy |
| 0917T | Insertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and ther | Nevada Prior Authorization List, Pg 132 Original policy |
| 0918T | Insertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and ther | Nevada Prior Authorization List, Pg 132 Original policy |
| 0919T | Removal of a permanent cardiac contractility modulation-defibrillation system component(s); pulse generator only | Nevada Prior Authorization List, Pg 132 Original policy |
| 0920T | Removal of a permanent cardiac contractility modulation-defibrillation system component(s); single transvenous pacing lead only | Nevada Prior Authorization List, Pg 132 Original policy |
| 0921T | Removal of a permanent cardiac contractility modulation-defibrillation system component(s); single transvenous defibrillation lead only | Nevada Prior Authorization List, Pg 132 Original policy |
| 0922T | Removal of a permanent cardiac contractility modulation-defibrillation system component(s); dual (pacing and defibrillation) transvenous leads only | Nevada Prior Authorization List, Pg 133 Original policy |
| 0923T | Removal and replacement of permanent cardiac contractility modulationdefibrillation pulse generator only | Nevada Prior Authorization List, Pg 133 Original policy |
| 0924T | Repositioning of previously implanted cardiac contractility modulation- defibrillation transvenous electrode(s)/lead(s), including fluoroscopic guidance and programming of sens | Nevada Prior Authorization List, Pg 133 Original policy |
| 0925T | Relocation of skin pocket for implanted cardiac contractility modulation- defibrillation pulse generator | Nevada Prior Authorization List, Pg 133 Original policy |
| 0926T | Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values | Nevada Prior Authorization List, Pg 133 Original policy |
| 0927T | Interrogation device evaluation (in person) with analysis, review, and report, including connection, recording, and disconnection, per patient encounter, implantable cardiac c | Nevada Prior Authorization List, Pg 133 Original policy |
| 0928T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation-defibrillation system with interim analysis and report(s) by a physician or other qua | Nevada Prior Authorization List, Pg 133 Original policy |
| 0929T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation-defibrillation system, remote data acquisition(s), receipt of transmissions, technici | Nevada Prior Authorization List, Pg 133 Original policy |
| 0930T | Electrophysiologic evaluation of cardiac contractility modulation-defibrillator leads, including defibrillation-threshold evaluation (induction of arrhythmia, evaluation of se | Nevada Prior Authorization List, Pg 133 Original policy |
| 0931T | Electrophysiologic evaluation of cardiac contractility modulation-defibrillator leads, including defibrillation-threshold evaluation (induction of arrhythmia, evaluation of se | Nevada Prior Authorization List, Pg 133 Original policy |
| 0933T | Transcatheter implantation of wireless left atrial pressure sensor for long-term left atrial pressure monitoring, including sensor calibration and deployment, right heart cath | Nevada Prior Authorization List, Pg 133 Original policy |
| 0934T | Remote monitoring of a wireless left atrial pressure sensor for up to 30 days, including data from daily uploads of left atrial pressure recordings, interpretation(s) and tren | Nevada Prior Authorization List, Pg 133 Original policy |
| 0935T | Cystourethroscopy with renal pelvic sympathetic denervation, radiofrequency ablation, retrograde ureteral approach, including insertion of guide wire, selective placement of u | Nevada Prior Authorization List, Pg 133 Original policy |
| 0948T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation system with interim analysis, review and report(s) by a physician or other qualified | Nevada Prior Authorization List, Pg 133 Original policy |
| 0949T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation system, remote data acquisition(s), receipt of transmissions, technician review, tech | Nevada Prior Authorization List, Pg 133 Original policy |
| 0951T | Totally implantable active middle ear hearing implant; initial placement, including mastoidectomy, placement of and attachment to sound processor | Nevada Prior Authorization List, Pg 133 Original policy |
| 0952T | Totally implantable active middle ear hearing implant; revision or replacement, with mastoidectomy and replacement of sound processor | Nevada Prior Authorization List, Pg 133 Original policy |
| 0953T | Totally implantable active middle ear hearing implant; revision or replacement, without mastoidectomy and replacement of sound processor | Nevada Prior Authorization List, Pg 133 Original policy |
| 0954T | Totally implantable active middle ear hearing implant; replacement of sound processor only, with attachment to existing transducers | Nevada Prior Authorization List, Pg 133 Original policy |
| 0955T | Totally implantable active middle ear hearing implant; removal, including removal of sound processor and all implant components | Nevada Prior Authorization List, Pg 133 Original policy |
| 0964T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; single arch, without mandibular advancement mecha | Nevada Prior Authorization List, Pg 133 Original policy |
| 0965T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; dual arch, with additional mandibular advancement | Nevada Prior Authorization List, Pg 133 Original policy |
| 0966T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; dual arch, with additional mandibular advancement | Nevada Prior Authorization List, Pg 134 Original policy |
| 0970T | Ablation, benign breast tumor (eg, fibroadenoma), percutaneous, laser, including imaging guidance when performed, each tumor | Nevada Prior Authorization List, Pg 134 Original policy |
| 0971T | Ablation, malignant breast tumor(s), percutaneous, laser, including imaging guidance when performed, unilateral | Nevada Prior Authorization List, Pg 134 Original policy |
| 0978T | Submucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil | Nevada Prior Authorization List, Pg 134 Original policy |
| 0979T | Submucosal cryolysis therapy; soft palate only | Nevada Prior Authorization List, Pg 134 Original policy |
| 0980T | Submucosal cryolysis therapy; base of tongue and lingual tonsil only | Nevada Prior Authorization List, Pg 134 Original policy |
| A0430 | Fixed Wing Air Transport | Nevada Prior Authorization List, Pg 134 Original policy |
| A0431 | Rotary Wing Air Transport | Nevada Prior Authorization List, Pg 134 Original policy |
| A0435 | Fixed Wing Air Mileage | Nevada Prior Authorization List, Pg 134 Original policy |
| A0436 | Rotary Wing Air Mileage | Nevada Prior Authorization List, Pg 134 Original policy |