Anthem Blue Cross and Blue Shield Nevada prior authorization, page 77
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 |
|---|---|---|
| K0837 | POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POU | Nevada Prior Authorization List, Pg 155 Original policy |
| K0838 | POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0839 | POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 60 | Nevada Prior Authorization List, Pg 155 Original policy |
| K0840 | POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUN | Nevada Prior Authorization List, Pg 155 Original policy |
| K0841 | POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCL | Nevada Prior Authorization List, Pg 155 Original policy |
| K0842 | POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 3 | Nevada Prior Authorization List, Pg 155 Original policy |
| K0843 | POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 P | Nevada Prior Authorization List, Pg 155 Original policy |
| K0848 | POWER WHEELCHAIR, GROUP 3 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0849 | POWER WHEELCHAIR, GROUP 3 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0850 | POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0851 | POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0852 | POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0853 | POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY, 451 TO 600 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0854 | POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE | Nevada Prior Authorization List, Pg 156 Original policy |
| K0855 | POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE | Nevada Prior Authorization List, Pg 156 Original policy |
| K0856 | POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUD | Nevada Prior Authorization List, Pg 156 Original policy |
| K0857 | POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 | Nevada Prior Authorization List, Pg 156 Original policy |
| K0858 | POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POU | Nevada Prior Authorization List, Pg 156 Original policy |
| K0859 | POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS | Nevada Prior Authorization List, Pg 156 Original policy |
| K0860 | POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 60 | Nevada Prior Authorization List, Pg 156 Original policy |
| K0861 | POWER WHEELCHAIR, GROUP 3 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCL | Nevada Prior Authorization List, Pg 156 Original policy |
| K0862 | POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 P | Nevada Prior Authorization List, Pg 156 Original policy |
| K0863 | POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO | Nevada Prior Authorization List, Pg 156 Original policy |
| K0864 | POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 PO | Nevada Prior Authorization List, Pg 156 Original policy |
| K0868 | POWER WHEELCHAIR, GROUP 4 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS | Nevada Prior Authorization List, Pg 156 Original policy |
| K0869 | POWER WHEELCHAIR, GROUP 4 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS | Nevada Prior Authorization List, Pg 156 Original policy |
| K0870 | POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS | Nevada Prior Authorization List, Pg 156 Original policy |
| K0871 | POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS | Nevada Prior Authorization List, Pg 156 Original policy |
| K0877 | POWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUD | Nevada Prior Authorization List, Pg 156 Original policy |
| K0878 | POWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 | Nevada Prior Authorization List, Pg 156 Original policy |
| K0879 | POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POU | Nevada Prior Authorization List, Pg 156 Original policy |
| K0880 | POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT 451 TO 600 POUNDS | Nevada Prior Authorization List, Pg 156 Original policy |
| K0884 | POWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCL | Nevada Prior Authorization List, Pg 156 Original policy |
| K0885 | POWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR, WEIGHT CAPACITY UP TO AND INCLUDING 300 POUND | Nevada Prior Authorization List, Pg 156 Original policy |
| K0886 | POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 P | Nevada Prior Authorization List, Pg 156 Original policy |
| K0890 | POWER WHEELCHAIR, GROUP 5 PEDIATRIC, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLU | Nevada Prior Authorization List, Pg 156 Original policy |
| K0891 | POWER WHEELCHAIR, GROUP 5 PEDIATRIC, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INC | Nevada Prior Authorization List, Pg 156 Original policy |
| K0899 | Power mobility device, not coded by DME PDAC or does not meet criteria | Nevada Prior Authorization List, Pg 156 Original policy |
| K1007 | Bilateral hip, knee, ankle, foot device, powered, includes pelvic component, single or double upright(s), knee joints any type, with or without ankle joints any type, includes | Nevada Prior Authorization List, Pg 157 Original policy |
| K1018 | External upper limb tremor stimulator of the peripheral nerves of the wrist | Nevada Prior Authorization List, Pg 157 Original policy |
| K1024 | Nonpneumatic compression controller with sequential calibrated gradient pressure | Nevada Prior Authorization List, Pg 157 Original policy |
| K1025 | Nonpneumatic sequential compression garment, full arm | Nevada Prior Authorization List, Pg 157 Original policy |
| K1027 | Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment | Nevada Prior Authorization List, Pg 157 Original policy |
| K1030 | External recharging system for battery (internal) for use with implanted cardiac contractility modulation generator, replacement only | Nevada Prior Authorization List, Pg 157 Original policy |
| K1031 | Nonpneumatic compression controller without calibrated gradient pressure | Nevada Prior Authorization List, Pg 157 Original policy |
| K1032 | Nonpneumatic sequential compression garment, full leg | Nevada Prior Authorization List, Pg 157 Original policy |
| K1033 | Nonpneumatic sequential compression garment, half leg | Nevada Prior Authorization List, Pg 157 Original policy |
| L2006 | Knee-ankle-foot (KAF) device, any material, single or double upright, swing and stance phase microprocessor control with adjustability, includes all components (e.g., sensors | Nevada Prior Authorization List, Pg 157 Original policy |
| L5987 | Shank Ft W Vert Load Pylon | Nevada Prior Authorization List, Pg 157 Original policy |
| L8045 | Auricular Prosthesis | Nevada Prior Authorization List, Pg 157 Original policy |