Anthem Blue Cross and Blue Shield Nevada prior authorization, page 7
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 |
|---|---|---|
| 21244 | Reconstruction, Mandible, Extraoral, W/Transosteal Bone Plate | Nevada Prior Authorization List, Pg 14 Original policy |
| 21245 | Reconstruction, Mandible/Maxilla, Subperiosteal Implant; Partial | Nevada Prior Authorization List, Pg 14 Original policy |
| 21246 | Reconstruction, Mandible/Maxilla, Subperiosteal Implant; Complete | Nevada Prior Authorization List, Pg 14 Original policy |
| 21247 | Reconstruction, Mandibular Condyle W/Bone & Cartilage Autografts | Nevada Prior Authorization List, Pg 14 Original policy |
| 21255 | Reconstruction, Zygomatic Arch/Glenoid Fossa W/Bone & Cartilage (Includes Obtaining Autografts) | Nevada Prior Authorization List, Pg 14 Original policy |
| 21256 | Reconstruction, Orbit W/Osteotomies & Bone Grafts (Includes Obtaining Autografts) | Nevada Prior Authorization List, Pg 14 Original policy |
| 21270 | Malar Augmentation, Prosthetic Matl | Nevada Prior Authorization List, Pg 14 Original policy |
| 21275 | Secondary Revision, Orbitocraniofacial Reconstruction | Nevada Prior Authorization List, Pg 14 Original policy |
| 21315 | Closed treatment of nasal bone fracture with manipulation; without stabilization | Nevada Prior Authorization List, Pg 14 Original policy |
| 21320 | Closed treatment of nasal bone fracture with manipulation; with stabilization | Nevada Prior Authorization List, Pg 14 Original policy |
| 21325 | Open Treatment, Nasal Fx; Uncomplicated | Nevada Prior Authorization List, Pg 14 Original policy |
| 21330 | Open Treatment, Nasal Fx; Complicated, W/Int &/Or Ext Skeletal Fixation | Nevada Prior Authorization List, Pg 15 Original policy |
| 21335 | Open Treatment, Nasal Fx; W/Concomitant Open Treatment, Fxd Septum | Nevada Prior Authorization List, Pg 15 Original policy |
| 21336 | Open Treatment, Nasal Septal Fx, W/Wo Stabilization | Nevada Prior Authorization List, Pg 15 Original policy |
| 21337 | Closed Treatment, Nasal Septal Fx, W/Wo Stabilization | Nevada Prior Authorization List, Pg 15 Original policy |
| 21356 | Open Treatment, Depressed Zygomatic Arch Fx | Nevada Prior Authorization List, Pg 15 Original policy |
| 21550 | Bx, Soft Tissue, Neck/Thorax | Nevada Prior Authorization List, Pg 15 Original policy |
| 21552 | Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater | Nevada Prior Authorization List, Pg 15 Original policy |
| 21554 | Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5 cm or greater | Nevada Prior Authorization List, Pg 15 Original policy |
| 21555 | Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm | Nevada Prior Authorization List, Pg 15 Original policy |
| 21556 | Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cm | Nevada Prior Authorization List, Pg 15 Original policy |
| 21557 | Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; less than 5 cm | Nevada Prior Authorization List, Pg 15 Original policy |
| 21685 | Hyoid Myotomy and Suspension | Nevada Prior Authorization List, Pg 15 Original policy |
| 21740 | Reconstructive Repair, Pectus Excavatum/Carinatum; Open | Nevada Prior Authorization List, Pg 15 Original policy |
| 21742 | Reconstructive Repair, Pectus Excavatum/Carinatum; Minimal Invasive Approach, W/O Thoracoscopy | Nevada Prior Authorization List, Pg 15 Original policy |
| 21743 | Reconstructive Repair, Pectus Excavatum/Carinatum; Minimal Invasive Approach, W/Thoracoscopy | Nevada Prior Authorization List, Pg 15 Original policy |
| 21811 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs | Nevada Prior Authorization List, Pg 15 Original policy |
| 21812 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs | Nevada Prior Authorization List, Pg 15 Original policy |
| 21813 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 7 or more ribs | Nevada Prior Authorization List, Pg 15 Original policy |
| 21920 | Bx, Soft Tissue, Back/Flank; Superficial | Nevada Prior Authorization List, Pg 15 Original policy |
| 21930 | Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm | Nevada Prior Authorization List, Pg 15 Original policy |
| 21931 | Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater | Nevada Prior Authorization List, Pg 15 Original policy |
| 21932 | Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); less than 5 cm | Nevada Prior Authorization List, Pg 15 Original policy |
| 21933 | Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greater | Nevada Prior Authorization List, Pg 15 Original policy |
| 22206 | Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral bo | Nevada Prior Authorization List, Pg 15 Original policy |
| 22207 | Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral bo | Nevada Prior Authorization List, Pg 15 Original policy |
| 22208 | Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral bo | Nevada Prior Authorization List, Pg 15 Original policy |
| 22210 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical | Nevada Prior Authorization List, Pg 15 Original policy |
| 22212 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic | Nevada Prior Authorization List, Pg 15 Original policy |
| 22214 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar | Nevada Prior Authorization List, Pg 16 Original policy |
| 22216 | Osteotomy, Spine, Posterior/Posterolateral Approach, 1 Vertebral Segment; Add'l Segment | Nevada Prior Authorization List, Pg 16 Original policy |
| 22220 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical | Nevada Prior Authorization List, Pg 16 Original policy |
| 22222 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic | Nevada Prior Authorization List, Pg 16 Original policy |
| 22224 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar | Nevada Prior Authorization List, Pg 16 Original policy |
| 22226 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary proce | Nevada Prior Authorization List, Pg 16 Original policy |
| 22505 | Manipulation, Spine, Requiring Anesthesia, Any Region | Nevada Prior Authorization List, Pg 16 Original policy |
| 22510 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic | Nevada Prior Authorization List, Pg 16 Original policy |
| 22511 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral | Nevada Prior Authorization List, Pg 16 Original policy |
| 22512 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cerv | Nevada Prior Authorization List, Pg 16 Original policy |
| 22513 | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 verteb | Nevada Prior Authorization List, Pg 16 Original policy |