Anthem Blue Cross and Blue Shield Nevada prior authorization, page 62

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
Code	Description	Source
A7028	Oral cushion for combination oral/nasal mask, replacement only, each	Nevada Prior Authorization List, Pg 135 Original policy
A7029	Nasal pillows for combination oral/nasal mask, replacement only, pair	Nevada Prior Authorization List, Pg 135 Original policy
A7030	Full Face Mask Used With Positive Airway Pressure Device, Each	Nevada Prior Authorization List, Pg 135 Original policy
A7031	Face Mask Interface, Replacement For Full Face Mask, Each	Nevada Prior Authorization List, Pg 135 Original policy
A7032	Cushion for use on nasal mask interface, replacement only, each	Nevada Prior Authorization List, Pg 135 Original policy
A7033	Pillow for use on nasal cannula type interface, replacement only, pair	Nevada Prior Authorization List, Pg 135 Original policy
A7034	Nasal Interface (Mask Or Cannula Type) Used With Positive Airway Press	Nevada Prior Authorization List, Pg 135 Original policy
A7035	Headgear Used With Positive Airway Pressure Device	Nevada Prior Authorization List, Pg 135 Original policy
A7036	Chinstrap Used With Positive Airway Pressure Device	Nevada Prior Authorization List, Pg 136 Original policy
A7037	Tubing Used With Positive Airway Pressure Device	Nevada Prior Authorization List, Pg 136 Original policy
A7038	Filter, Disposable, Used With Positive Airway Pressure Device	Nevada Prior Authorization List, Pg 136 Original policy
A7039	Filter, Non Disposable, Used With Positive Airway Pressure Device	Nevada Prior Authorization List, Pg 136 Original policy
A7044	Oral Interface Used With Positive Airway Pressure Device, Each	Nevada Prior Authorization List, Pg 136 Original policy
A7045	Repl exhalation port for PAP	Nevada Prior Authorization List, Pg 136 Original policy
A7046	Water chamber for humidifier, used with positive airway pressure device, replacement, each	Nevada Prior Authorization List, Pg 136 Original policy
A9268	Programmer for transient, orally ingested capsule	Nevada Prior Authorization List, Pg 136 Original policy
A9269	Programmable, transient, orally ingested capsule, for use with external programmer, per month	Nevada Prior Authorization List, Pg 136 Original policy
A9513	Lutetium Lu 177, dotatate, therapeutic, 1 mCi	Nevada Prior Authorization List, Pg 136 Original policy
A9543	Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries	Nevada Prior Authorization List, Pg 136 Original policy
A9606	Radium RA-223 dichloride, therapeutic, per UCI	Nevada Prior Authorization List, Pg 136 Original policy
A9607	Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie	Nevada Prior Authorization List, Pg 136 Original policy
B4164	Parenteral 50% Dextrose Solu	Nevada Prior Authorization List, Pg 136 Original policy
B4168	Parenteral Sol Amino Acid 3.	Nevada Prior Authorization List, Pg 136 Original policy
B4172	Parenteral Sol Amino Acid 5.	Nevada Prior Authorization List, Pg 136 Original policy
B4176	Parenteral Sol Amino Acid 7	Nevada Prior Authorization List, Pg 136 Original policy
B4178	Parenteral Sol Amino Acid >	Nevada Prior Authorization List, Pg 136 Original policy
B4180	Parenteral Sol Carb > 50%	Nevada Prior Authorization List, Pg 136 Original policy
B4185	Parenteral nutrition solution, not otherwise specified, 10 grams lipids	Nevada Prior Authorization List, Pg 136 Original policy
B4187	Omegaven, 10 g lipids	Nevada Prior Authorization List, Pg 136 Original policy
B4189	Parenteral Sol Amino Acid &	Nevada Prior Authorization List, Pg 136 Original policy
B4193	Parenteral Sol 52-73 Gm Prot	Nevada Prior Authorization List, Pg 136 Original policy
B4197	Parenteral Sol 74-100 Gm Pro	Nevada Prior Authorization List, Pg 136 Original policy
B4199	Parenteral Sol > 100gm Prote	Nevada Prior Authorization List, Pg 136 Original policy
B4216	Parenteral Nutrition Additiv	Nevada Prior Authorization List, Pg 136 Original policy
B4220	Parenteral Supply Kit Premix	Nevada Prior Authorization List, Pg 136 Original policy
B4222	Parenteral Supply Kit Homemi	Nevada Prior Authorization List, Pg 136 Original policy
B4224	Parenteral Administration Ki	Nevada Prior Authorization List, Pg 136 Original policy
B5000	Parenteral Sol Renal-Amirosy	Nevada Prior Authorization List, Pg 136 Original policy
B5100	Parenteral Sol Hepatic-Fream	Nevada Prior Authorization List, Pg 136 Original policy
B5200	Parenteral Sol Stres-Brnch C	Nevada Prior Authorization List, Pg 136 Original policy
B9004	Parenteral Infus Pump Portab	Nevada Prior Authorization List, Pg 136 Original policy
B9006	Parenteral Infus Pump Statio	Nevada Prior Authorization List, Pg 136 Original policy
C1605	Pacemaker, leadless, dual chamber (right atrial and right ventricular implantable components), rate-responsive, including all necessary components for implantation	Nevada Prior Authorization List, Pg 137 Original policy
C1721	Cardioverter-defibrillator, dual chamber (implantable)	Nevada Prior Authorization List, Pg 137 Original policy
C1722	Cardioverter-defibrillator, single chamber (implantable)	Nevada Prior Authorization List, Pg 137 Original policy
C1726	Catheter, balloon dilatation, nonvascular	Nevada Prior Authorization List, Pg 137 Original policy
C1734	Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable)	Nevada Prior Authorization List, Pg 137 Original policy
C1735	Catheter(s), intravascular for renal denervation, radiofrequency, including all single use system components	Nevada Prior Authorization List, Pg 137 Original policy
C1736	Catheter(s), intravascular for renal denervation, ultrasound, including all single use system components	Nevada Prior Authorization List, Pg 137 Original policy
C1763	Connective tissue, nonhuman (includes synthetic)	Nevada Prior Authorization List, Pg 137 Original policy

Sources

Nevada Prior Authorization List