Anthem Blue Cross and Blue Shield Nevada prior authorization, page 65
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 |
|---|---|---|
| C9602 | Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch | Nevada Prior Authorization List, Pg 140 Original policy |
| C9603 | Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary art | Nevada Prior Authorization List, Pg 140 Original policy |
| C9604 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug- eluting intracoronary | Nevada Prior Authorization List, Pg 140 Original policy |
| C9605 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug- eluting intracoronary | Nevada Prior Authorization List, Pg 140 Original policy |
| C9607 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluti | Nevada Prior Authorization List, Pg 140 Original policy |
| C9608 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluti | Nevada Prior Authorization List, Pg 141 Original policy |
| C9727 | Insertion of implants into the soft palate; minimum of 3 implants | Nevada Prior Authorization List, Pg 141 Original policy |
| C9734 | Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (mr) guidance | Nevada Prior Authorization List, Pg 141 Original policy |
| C9751 | Bronchoscopy, rigid or flexible, transbronchial ablation of lesion(s) by microwave energy, including fluoroscopic guidance, when performed, with computed tomography acquisiti | Nevada Prior Authorization List, Pg 141 Original policy |
| C9752 | Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum | Nevada Prior Authorization List, Pg 141 Original policy |
| C9762 | Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging | Nevada Prior Authorization List, Pg 141 Original policy |
| C9763 | Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging | Nevada Prior Authorization List, Pg 141 Original policy |
| C9764 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, includes angioplasty within the sam | Nevada Prior Authorization List, Pg 141 Original policy |
| C9765 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, and transluminal stent placement(s) | Nevada Prior Authorization List, Pg 141 Original policy |
| C9766 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and atherectomy, includes angioplast | Nevada Prior Authorization List, Pg 141 Original policy |
| C9767 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and transluminal stent placement(s) | Nevada Prior Authorization List, Pg 141 Original policy |
| C9772 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy, includes angioplasty within the same vessel (s), when perfo | Nevada Prior Authorization List, Pg 141 Original policy |
| C9773 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty | Nevada Prior Authorization List, Pg 141 Original policy |
| C9774 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel | Nevada Prior Authorization List, Pg 141 Original policy |
| C9775 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includ | Nevada Prior Authorization List, Pg 141 Original policy |
| C9781 | Arthroscopy, shoulder, surgical; with implantation of subacromial spacer (e.g., balloon), includes debridement (e.g., limited or extensive), subacromial decompression, acromio | Nevada Prior Authorization List, Pg 141 Original policy |
| C9785 | Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components | Nevada Prior Authorization List, Pg 141 Original policy |
| C9796 | Repair of enterocutaneous fistula small intestine or colon (excluding anorectal fistula) with plug (e.g., porcine small intestine submucosa [SIS]) | Nevada Prior Authorization List, Pg 141 Original policy |
| C9807 | Nerve stimulator, percutaneous, peripheral (e.g., sprint peripheral nerve stimulation system), including electrode and all disposable system components, non-opioid medical dev | Nevada Prior Authorization List, Pg 141 Original policy |
| C9808 | Nerve cryoablation probe (e.g., cryoice, cryosphere, cryosphere max, cryoice cryosphere, cryoice cryo2), including probe and all disposable system components, non-opioid medic | Nevada Prior Authorization List, Pg 141 Original policy |
| C9809 | Cryoneurolysis needle (e.g., iovera system), including needle/tip and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid med | Nevada Prior Authorization List, Pg 141 Original policy |
| D7810 | open reduction of dislocation | Nevada Prior Authorization List, Pg 141 Original policy |
| D7820 | closed reduction of dislocation | Nevada Prior Authorization List, Pg 141 Original policy |
| D7830 | manipulation under anesthesia | Nevada Prior Authorization List, Pg 141 Original policy |
| D7840 | condylectomy | Nevada Prior Authorization List, Pg 141 Original policy |
| D7850 | surgical discectomy, with/without implant | Nevada Prior Authorization List, Pg 141 Original policy |
| D7852 | disc repair | Nevada Prior Authorization List, Pg 141 Original policy |
| D7854 | synovectomy | Nevada Prior Authorization List, Pg 142 Original policy |
| D7856 | myotomy | Nevada Prior Authorization List, Pg 142 Original policy |
| D7858 | joint reconstruction | Nevada Prior Authorization List, Pg 142 Original policy |
| D7860 | arthrotomy | Nevada Prior Authorization List, Pg 142 Original policy |
| D7865 | arthroplasty | Nevada Prior Authorization List, Pg 142 Original policy |
| D7870 | arthrocentesis | Nevada Prior Authorization List, Pg 142 Original policy |
| D7871 | non-arthroscopic lysis and lavage | Nevada Prior Authorization List, Pg 142 Original policy |
| D7873 | arthroscopy: lavage and lysis of adhesions | Nevada Prior Authorization List, Pg 142 Original policy |
| D7874 | arthroscopy: disc repositioning and stabilization | Nevada Prior Authorization List, Pg 142 Original policy |
| D7875 | arthroscopy: synovectomy | Nevada Prior Authorization List, Pg 142 Original policy |
| D7876 | arthroscopy: discectomy | Nevada Prior Authorization List, Pg 142 Original policy |
| D7877 | arthroscopy: debridement | Nevada Prior Authorization List, Pg 142 Original policy |
| D7940 | osteoplasty - for orthognathic deformities | Nevada Prior Authorization List, Pg 142 Original policy |
| D7941 | osteotomy - mandibular rami | Nevada Prior Authorization List, Pg 142 Original policy |
| D7943 | osteotomy - mandibular rami with bone graft; includes obtaining the graft | Nevada Prior Authorization List, Pg 142 Original policy |
| D7944 | osteotomy - segmented or subapical | Nevada Prior Authorization List, Pg 142 Original policy |
| D7945 | osteotomy - body of mandible | Nevada Prior Authorization List, Pg 142 Original policy |
| D7946 | LeFort I (maxilla - total) | Nevada Prior Authorization List, Pg 142 Original policy |