Anthem Blue Cross and Blue Shield Nevada prior authorization, page 61
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 |
|---|---|---|
| A0888 | Noncovered Ambulance Mileage | Nevada Prior Authorization List, Pg 134 Original policy |
| A2001 | Innovamatrix ac, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2002 | Mirragen advanced wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2004 | Xcellistem, 1 mg/Original description: Miscellaneous with Motor <27.85, without comorbidities,10/2019 description: Miscellaneous M <46.50 and A >=77.50.,witho | Nevada Prior Authorization List, Pg 134 Original policy |
| A2005 | Microlyte matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2006 | Novosorb synpath dermal matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2007 | Restrata, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2008 | Theragenesis, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2009 | Symphony, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2010 | Apis, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2011 | Supra sdrm, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2012 | Suprathel, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2013 | Innovamatrix fs, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2014 | Omeza collagen matrix or omeza complete matrix, per 100 mg | Nevada Prior Authorization List, Pg 134 Original policy |
| A2015 | Phoenix wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2016 | Permeaderm b, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2017 | PermeaDerm Glove, each | Nevada Prior Authorization List, Pg 134 Original policy |
| A2018 | Permeaderm c, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2019 | Kerecis omega3 marigen shield, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2020 | Ac5 advanced wound system (ac5) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2021 | Neomatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2022 | Innovaburn or innovamatrix xl, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2023 | InnovaMatrix PD, 1 mg | Nevada Prior Authorization List, Pg 134 Original policy |
| A2024 | Resolve matrix or xenopatch, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 134 Original policy |
| A2025 | Miro3d, per cubic centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 135 Original policy |
| A2026 | Restrata MiniMatrix, 5 mg | Nevada Prior Authorization List, Pg 135 Original policy |
| A2027 | Matriderm, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 135 Original policy |
| A2028 | Micromatrix flex, per mg | Nevada Prior Authorization List, Pg 135 Original policy |
| A2029 | Mirotract wound matrix sheet, per cubic centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 135 Original policy |
| A2030 | Miro3D fibers, per mg | Nevada Prior Authorization List, Pg 135 Original policy |
| A2031 | Mirodry wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 135 Original policy |
| A2032 | Myriad matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 135 Original policy |
| A2033 | Myriad Morcells, 4 mg | Nevada Prior Authorization List, Pg 135 Original policy |
| A2034 | Foundation drs solo, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 135 Original policy |
| A2035 | Corplex P or Theracor P or Allacor P, per mg | Nevada Prior Authorization List, Pg 135 Original policy |
| A4100 | Non-sheet form skin substitute, fda cleared as a device, not otherwise specified (list in addition to primary procedure) | Nevada Prior Authorization List, Pg 135 Original policy |
| A4341 | Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each | Nevada Prior Authorization List, Pg 135 Original policy |
| A4342 | Accessories for patient inserted indwelling intraurethral drainage device with valve, replacement only, each | Nevada Prior Authorization List, Pg 135 Original policy |
| A4438 | Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each | Nevada Prior Authorization List, Pg 135 Original policy |
| A4468 | Exsufflation belt, includes all supplies and accessories | Nevada Prior Authorization List, Pg 135 Original policy |
| A4540 | Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm | Nevada Prior Authorization List, Pg 135 Original policy |
| A4542 | Supplies and accessories for external upper limb tremor stimulator of the peripheral nerves of the wrist | Nevada Prior Authorization List, Pg 135 Original policy |
| A4543 | Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month | Nevada Prior Authorization List, Pg 135 Original policy |
| A4544 | Electrode for external lower extremity nerve stimulator for restless legs syndrome | Nevada Prior Authorization List, Pg 135 Original policy |
| A4545 | Supplies and accessories for external tibial nerve stimulator (e.g., socks, gel pads, electrodes, etc.), needed for one month | Nevada Prior Authorization List, Pg 135 Original policy |
| A4575 | Hyperbaric O2 Chamber Disps | Nevada Prior Authorization List, Pg 135 Original policy |
| A4596 | Cranial electrotherapy stimulation (ces) system supplies and accessories, per month | Nevada Prior Authorization List, Pg 135 Original policy |
| A4600 | SLEEVE FOR INTERMITTENT LIMB COMPRESSION DEVICE, REPLACEMENT ONLY, EACH | Nevada Prior Authorization List, Pg 135 Original policy |
| A4604 | Tubing with integrated heating element for use with positive airway pressure device | Nevada Prior Authorization List, Pg 135 Original policy |
| A7027 | Combination oral/nasal mask, used with continuous positive airway pressure | Nevada Prior Authorization List, Pg 135 Original policy |