Anthem Blue Cross and Blue Shield Nevada prior authorization, page 67

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
E0683	Non-pneumatic, non-sequential, peristaltic wave compression pump	Nevada Prior Authorization List, Pg 143 Original policy
E0721	Transcutaneous electrical nerve stimulatory, stimulates nerves in the auricular region	Nevada Prior Authorization List, Pg 143 Original policy
E0732	Cranial electrotherapy stimulation (ces) system, any type	Nevada Prior Authorization List, Pg 143 Original policy
E0734	External upper limb tremor stimulator of the peripheral nerves of the wrist	Nevada Prior Authorization List, Pg 143 Original policy
E0735	Non-invasive vagus nerve stimulator	Nevada Prior Authorization List, Pg 143 Original policy
E0736	Transcutaneous tibial nerve stimulator	Nevada Prior Authorization List, Pg 143 Original policy
E0737	Transcutaneous tibial nerve stimulator, controlled by phone application	Nevada Prior Authorization List, Pg 143 Original policy
E0738	Upper extremity rehabilitation system providing active assistance to facilitate muscle re-education, includes microprocessor, all components and accessories	Nevada Prior Authorization List, Pg 143 Original policy
E0739	Rehabilitation system with interactive interface providing active assistance in rehabilitation therapy, includes all components and accessories, motors, microprocessors, senso	Nevada Prior Authorization List, Pg 143 Original policy
E0743	External lower extremity nerve stimulator for restless legs syndrome, each	Nevada Prior Authorization List, Pg 143 Original policy
E0745	Neuromuscular Stim For Shock	Nevada Prior Authorization List, Pg 144 Original policy
E0746	Electromyograph Biofeedback	Nevada Prior Authorization List, Pg 144 Original policy
E0748	Elec Osteogen Stim Spinal	Nevada Prior Authorization List, Pg 144 Original policy
E0752	Implantable neurostimulator electrode, each	Nevada Prior Authorization List, Pg 144 Original policy
E0754	Patient programmer (external) for use with implantable programmable neurostimulator pulse generator	Nevada Prior Authorization List, Pg 144 Original policy
E0756	Implantable Pulse Generator	Nevada Prior Authorization List, Pg 144 Original policy
E0760	Osteogen Ultrasound Stimltor	Nevada Prior Authorization List, Pg 144 Original policy
E0761	Non-Thermal Pulsed High Frequency Radiowaves, High Peak Power Electrom	Nevada Prior Authorization List, Pg 144 Original policy
E0762	Transcutaneous electrical joint stimulation device system, includes all accessories	Nevada Prior Authorization List, Pg 144 Original policy
E0764	Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer	Nevada Prior Authorization List, Pg 144 Original policy
E0765	FDA-approved nerve stimulator, for treatment of nausea and vomiting	Nevada Prior Authorization List, Pg 144 Original policy
E0769	Electric wound treatment dev	Nevada Prior Authorization List, Pg 144 Original policy
E0770	Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, n	Nevada Prior Authorization List, Pg 144 Original policy
E0782	Non-Programble Infusion Pump	Nevada Prior Authorization List, Pg 144 Original policy
E0783	Programmable Infusion Pump	Nevada Prior Authorization List, Pg 144 Original policy
E0786	Implantable Pump Replacement	Nevada Prior Authorization List, Pg 144 Original policy
E0986	Manual wheelchair accessory, power assist system	Nevada Prior Authorization List, Pg 144 Original policy
E1012	Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each	Nevada Prior Authorization List, Pg 144 Original policy
E1801	Static progressive stretch/patient actualized serial stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and ac	Nevada Prior Authorization List, Pg 144 Original policy
E1806	Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes	Nevada Prior Authorization List, Pg 144 Original policy
E1811	Static progressive stretch/patient actualized serial stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and acc	Nevada Prior Authorization List, Pg 144 Original policy
E1816	Static progressive stretch/patient actualized serial stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and ac	Nevada Prior Authorization List, Pg 144 Original policy
E1818	Static progressive stretch/patient actualized serial stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and acces	Nevada Prior Authorization List, Pg 144 Original policy
E1821	Replacement soft interface material/cuffs for bi-directional static progressive stretch device	Nevada Prior Authorization List, Pg 144 Original policy
E1831	Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories	Nevada Prior Authorization List, Pg 144 Original policy
E1832	Static progressive stretch finger device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories	Nevada Prior Authorization List, Pg 144 Original policy
E1841	Static progressive stretch/patient actualized serial stretch shoulder device, with or without range of motion adjustment, includes all components and accessories	Nevada Prior Authorization List, Pg 144 Original policy
E1905	Virtual reality cognitive behavioral therapy device (cbt), including pre- programmed therapy software	Nevada Prior Authorization List, Pg 144 Original policy
E2298	Complex rehabilitative power wheelchair accessory, power seat elevation system, any type	Nevada Prior Authorization List, Pg 144 Original policy
E3200	Gait modulation system, rhythmic auditory stimulation, including restricted therapy software, all components and accessories, prescription only	Nevada Prior Authorization List, Pg 144 Original policy
G0173	Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session	Nevada Prior Authorization List, Pg 144 Original policy
G0251	Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum five s	Nevada Prior Authorization List, Pg 145 Original policy
G0255	Current Perception Threshold/Sensory Nerve Conduction Test, Per Limb	Nevada Prior Authorization List, Pg 145 Original policy
G0260	Injection Procedure For Sacroiliac Joint; Provision Of Anesthetic, Ste	Nevada Prior Authorization List, Pg 145 Original policy
G0277	Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval	Nevada Prior Authorization List, Pg 145 Original policy
G0281	Electrical Stimulation, (Unattended), To One Or More Areas, For Chroni	Nevada Prior Authorization List, Pg 145 Original policy
G0282	Electrical Stimulation, (Unatteded), To One Or More Areas, For Wound	Nevada Prior Authorization List, Pg 145 Original policy
G0283	Electrical Stimulation (Unattended), To One Or More Areas For Indicati	Nevada Prior Authorization List, Pg 145 Original policy
G0289	Arthroscopy, Knee, Surgical, For Removal Of Loose Body, Foreign Body	Nevada Prior Authorization List, Pg 145 Original policy
G0295	Electromagnetic Stimulation, To One Or More Areas	Nevada Prior Authorization List, Pg 145 Original policy

Sources

Nevada Prior Authorization List