Anthem Blue Cross and Blue Shield Nevada prior authorization, page 68
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 |
|---|---|---|
| G0329 | Electromagntic tx for ulcers | Nevada Prior Authorization List, Pg 145 Original policy |
| G0330 | Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia ca | Nevada Prior Authorization List, Pg 145 Original policy |
| G0339 | Robot lin-radsurg com, first | Nevada Prior Authorization List, Pg 145 Original policy |
| G0340 | Robt lin-radsurg fractx 2-5 | Nevada Prior Authorization List, Pg 145 Original policy |
| G0341 | Percutaneous islet celltrans | Nevada Prior Authorization List, Pg 145 Original policy |
| G0342 | Laparoscopy islet cell trans | Nevada Prior Authorization List, Pg 145 Original policy |
| G0343 | Laparotomy islet cell transp | Nevada Prior Authorization List, Pg 145 Original policy |
| G0398 | Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart r | Nevada Prior Authorization List, Pg 145 Original policy |
| G0399 | Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow | Nevada Prior Authorization List, Pg 145 Original policy |
| G0400 | Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels | Nevada Prior Authorization List, Pg 145 Original policy |
| G0428 | Collagen Meniscus Implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex) | Nevada Prior Authorization List, Pg 145 Original policy |
| G0429 | Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active | Nevada Prior Authorization List, Pg 145 Original policy |
| G0448 | Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac v | Nevada Prior Authorization List, Pg 145 Original policy |
| G0458 | Low dose rate (ldr) prostate brachytherapy services, composite rate | Nevada Prior Authorization List, Pg 145 Original policy |
| G0460 | Autologous platelet rich plasma or other blood-derived product for non- diabetic chronic wounds/ulcers, including as applicable phlebotomy, centrifugation or mixing, and all ot | Nevada Prior Authorization List, Pg 145 Original policy |
| G0465 | Autologous platelet rich plasma (PRP) or other blood-derived product for diabetic chronic wounds/ulcers, using an FDA-cleared device for this indication, (includes as applicab | Nevada Prior Authorization List, Pg 145 Original policy |
| G2082 | Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care profes | Nevada Prior Authorization List, Pg 146 Original policy |
| G2083 | Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care profes | Nevada Prior Authorization List, Pg 146 Original policy |
| G2168 | Services performed by a physical therapist assistant in the home health setting in the delivery of a safe and effective physical therapy maintenance program, each 15 minutes | Nevada Prior Authorization List, Pg 146 Original policy |
| G9143 | Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s) | Nevada Prior Authorization List, Pg 146 Original policy |
| G9147 | Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of | Nevada Prior Authorization List, Pg 146 Original policy |
| G9840 | RAS (KRAS and NRAS) gene mutation testing performed before initiation of anti- EGFR MoAb | Nevada Prior Authorization List, Pg 146 Original policy |
| G9841 | RAS (KRAS and NRAS) gene mutation testing not performed before initiation of anti-EGFR MoAb | Nevada Prior Authorization List, Pg 146 Original policy |
| H0004 | Behavioral health counseling and therapy, per 15 minutes | Nevada Prior Authorization List, Pg 146 Original policy |
| H0006 | Alcohol and/or drug services; case management | Nevada Prior Authorization List, Pg 146 Original policy |
| H0015 | Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment p | Nevada Prior Authorization List, Pg 146 Original policy |
| H0017 | Behavioral health; residential (hospital residential treatment program), without room and board, per diem | Nevada Prior Authorization List, Pg 146 Original policy |
| H0019 | Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, pe | Nevada Prior Authorization List, Pg 146 Original policy |
| H0023 | Behavioral health outreach service (planned approach to reach a targeted population) | Nevada Prior Authorization List, Pg 146 Original policy |
| H0035 | Mental health partial hospitalization, treatment, less than 24 hours | Nevada Prior Authorization List, Pg 146 Original policy |
| H0038 | Self-help/peer services, per 15 minutes | Nevada Prior Authorization List, Pg 146 Original policy |
| H0039 | Assertive community treatment, face-to-face, per 15 minutes | Nevada Prior Authorization List, Pg 146 Original policy |
| H0040 | Assertive community treatment program, per diem | Nevada Prior Authorization List, Pg 146 Original policy |
| H2021 | Community-based wrap-around services, per 15 minutes | Nevada Prior Authorization List, Pg 146 Original policy |
| J0013 | Esketamine, nasal spray, 1 mg | Nevada Prior Authorization List, Pg 146 Original policy |
| J0129 | Injection, abatacept, 10 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) | Nevada Prior Authorization List, Pg 146 Original policy |
| J0135 | Adalimumab injection | Nevada Prior Authorization List, Pg 146 Original policy |
| J0139 | Injection, adalimumab, 1 mg | Nevada Prior Authorization List, Pg 146 Original policy |
| J0172 | Injection, aducanumab-avwa, 2 mg | Nevada Prior Authorization List, Pg 146 Original policy |
| J0174 | Lecanemab-irmb, for intravenous injection, 1 mg | Nevada Prior Authorization List, Pg 146 Original policy |
| J0175 | Injection, donanemab-azbt, 2 mg | Nevada Prior Authorization List, Pg 146 Original policy |
| J0177 | Injection, aflibercept HD, 1 mg | Nevada Prior Authorization List, Pg 146 Original policy |
| J0178 | Injection, aflibercept, 1 mg | Nevada Prior Authorization List, Pg 146 Original policy |
| J0179 | Injection, brolucizumab-dbll, 1 mg | Nevada Prior Authorization List, Pg 146 Original policy |
| J0180 | Agalsidase beta injection | Nevada Prior Authorization List, Pg 146 Original policy |
| J0202 | Injection, alemtuzumab, 1 mg | Nevada Prior Authorization List, Pg 146 Original policy |
| J0208 | Injection, sodium thiosulfate (Pedmark), 100 mg | Nevada Prior Authorization List, Pg 146 Original policy |
| J0217 | Injection, velmanase alfa-tycv, 1 mg | Nevada Prior Authorization List, Pg 146 Original policy |
| J0218 | Injection, olipudase alfa-rpcp, 1 mg | Nevada Prior Authorization List, Pg 146 Original policy |
| J0219 | Injection, avalglucosidase alfa-ngpt, 4 mg | Nevada Prior Authorization List, Pg 146 Original policy |