Anthem Blue Cross and Blue Shield Nevada prior authorization, page 75

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
J9217	Leuprolide Acetate Suspnsion	Nevada Prior Authorization List, Pg 153 Original policy
J9223	Injection, lurbinectedin, 0.1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9226	Histrelin implant (supprelin LA), 50 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9227	Injection, isatuximab-irfc, 10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9228	Injection, ipilimumab, 1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9229	Injection, inotuzumab ozogamicin, 0.1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9248	Injection, melphalan (Hepzato), 1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9256	Injection, nipocalimab-aahu, 3 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9262	Injection, omacetaxine mepesuccinate, 0.01 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9264	Injection, paclitaxel protein-bound particles, 1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9266	Injection, pegaspargase, per single dose vial	Nevada Prior Authorization List, Pg 153 Original policy
J9269	Injection, tagraxofusp-erzs, 10 micrograms	Nevada Prior Authorization List, Pg 153 Original policy
J9271	Injection, pembrolizumab, 1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9272	Injection, dostarlimab-gxly, 10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9273	Injection, tisotumab vedotin-tftv, 1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9274	Injection, tebentafusp-tebn, 1 microgram	Nevada Prior Authorization List, Pg 153 Original policy
J9275	Injection, cosibelimab-ipdl, 2 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9276	Injection, zanidatamab-hrii, 2 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9277	Injection, pembrolizumab, 1 mg and berahyaluronidase alfa-pmph	Nevada Prior Authorization List, Pg 153 Original policy
J9281	Mitomycin pyelocalyceal instillation, 1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9282	Mitomycin, intravesical instillation, 1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9286	Injection, glofitamab-gxbm, 2.5 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9289	Injection, nivolumab, 2 mg and hyaluronidase-nvhy	Nevada Prior Authorization List, Pg 153 Original policy
J9292	Injection, pemetrexed dipotassium, 10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9294	Injection, pemetrexed (Hospira), not therapeutically equivalent to J9305, 10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9296	Injection, pemetrexed (Accord), not therapeutically equivalent to J9305, 10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9297	Injection, pemetrexed (sandoz), not therapeutically equivalent to j9305, 10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9298	Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9299	Injection, nivolumab, 1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9301	Injection, obinutuzumab, 10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9302	Injection, ofatumumab, 10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9303	Injection, panitumumab, 10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9304	Injection, pemetrexed (pemfexy), 10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9305	Injection, pemetrexed, NOS,10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9306	Injection, pertuzumab, 1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9308	Injection, ramucirumab, 5 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9309	Injection, polatuzumab vedotin-piiq, 1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9312	Injection, rituximab, 10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9314	Injection, pemetrexed (Teva), not therapeutically equivalent to J9305, 10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9316	Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9317	Injection, sacituzumab govitecan-hziy, 2.5 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9318	Injection, romidepsin, nonlyophilized, 0.1 mg	Nevada Prior Authorization List, Pg 153 Original policy
J9319	Injection, romidepsin, lyophilized, 0.1 mg	Nevada Prior Authorization List, Pg 154 Original policy
J9321	Injection, epcoritamab-bysp, 0.16 mg	Nevada Prior Authorization List, Pg 154 Original policy
J9322	Injection, pemetrexed (BluePoint), not therapeutically equivalent to J9305, 10 mg	Nevada Prior Authorization List, Pg 154 Original policy
J9323	Injection, pemetrexed (hospira) not therapeutically equivalent to j9305, 10 mg	Nevada Prior Authorization List, Pg 154 Original policy
J9324	Injection, pemetrexed (pemrydi rtu), 10 mg	Nevada Prior Authorization List, Pg 154 Original policy
J9325	Injection, talimogene laherparepvec, per 1 million plaque forming units	Nevada Prior Authorization List, Pg 154 Original policy
J9326	Injection, telisotuzumab vedotin-tllv, 1 mg	Nevada Prior Authorization List, Pg 154 Original policy
J9329	Injection, tislelizumab-jsgr, 1mg	Nevada Prior Authorization List, Pg 154 Original policy

Sources

Nevada Prior Authorization List