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Anthem Blue Cross and Blue Shield Nevada prior authorization, page 78

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
CodeDescriptionSource
L8600Implant Breast Silicone/EqNevada Prior Authorization List, Pg 157 Original policy
L8607Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary suppliesNevada Prior Authorization List, Pg 157 Original policy
L8614COCHLEAR DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTSNevada Prior Authorization List, Pg 157 Original policy
L8619Cochlear Implant, External Speech Processor And Controller, Integrated System, ReplacementNevada Prior Authorization List, Pg 157 Original policy
L8627Cochlear Implant, External Speech Processor, Component, ReplacementNevada Prior Authorization List, Pg 157 Original policy
L8628Cochlear Implant, External Controller Component, ReplacementNevada Prior Authorization List, Pg 157 Original policy
L8678Electrical stimulator supplies (external) for use with implantable neurostimulator, per monthNevada Prior Authorization List, Pg 157 Original policy
L8679Implantable neurostimulator, pulse generator, any typeNevada Prior Authorization List, Pg 157 Original policy
L8680Implantable neurostimulator electrode, eachNevada Prior Authorization List, Pg 157 Original policy
L8681Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement onlyNevada Prior Authorization List, Pg 157 Original policy
L8682Implantable neurostimulator radiofrequency receiverNevada Prior Authorization List, Pg 157 Original policy
L8683Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiverNevada Prior Authorization List, Pg 157 Original policy
L8684Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladdeNevada Prior Authorization List, Pg 157 Original policy
L8685Implantable neurostimulator pulse generator, single array, rechargeable, includes extensionNevada Prior Authorization List, Pg 158 Original policy
L8686Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extensionNevada Prior Authorization List, Pg 158 Original policy
L8687Implantable neurostimulator pulse generator, dual array, rechargeable, includes extensionNevada Prior Authorization List, Pg 158 Original policy
L8688Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extensionNevada Prior Authorization List, Pg 158 Original policy
L8690AUDITORY OSSEOINTEGRATED DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTSNevada Prior Authorization List, Pg 158 Original policy
L8691Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, eachNevada Prior Authorization List, Pg 158 Original policy
L8692Auditory Osseointegrated Device, External Sound Processor, Used Without Osseointegration, Body Worn, Includes Headband ONevada Prior Authorization List, Pg 158 Original policy
L8693Auditory osseointegrated device abutment, any length, replacement onlyNevada Prior Authorization List, Pg 158 Original policy
L8694Auditory osseointegrated device, transducer/actuator, replacement only, eachNevada Prior Authorization List, Pg 158 Original policy
L8701Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, cNevada Prior Authorization List, Pg 158 Original policy
L8702Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessorieNevada Prior Authorization List, Pg 158 Original policy
Q2026Injection, Radiesse, 0.1mlNevada Prior Authorization List, Pg 158 Original policy
Q2028Injection, sculptra, 0.5 mgNevada Prior Authorization List, Pg 158 Original policy
Q2041Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR positive T cells, including leukapheresis and dose preparation procedures, per therapeutic doseNevada Prior Authorization List, Pg 158 Original policy
Q2042Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic doseNevada Prior Authorization List, Pg 158 Original policy
Q2043Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap- gm-csf, including leukapheresis and all other preparatory procedures, per infusionNevada Prior Authorization List, Pg 158 Original policy
Q2053Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic doseNevada Prior Authorization List, Pg 158 Original policy
Q2054Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic doseNevada Prior Authorization List, Pg 158 Original policy
Q2055Idecabtagene vicleucel, up to 510 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, pNevada Prior Authorization List, Pg 158 Original policy
Q2056Ciltacabtagene autoleucel, up to 100 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation proceduresNevada Prior Authorization List, Pg 158 Original policy
Q2057Afamitresgene autoleucel, including leukapheresis and dose preparation procedures, per therapeutic doseNevada Prior Authorization List, Pg 158 Original policy
Q2058Obecabtagene autoleucel, 10 up to 400 million cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per infusionNevada Prior Authorization List, Pg 159 Original policy
Q3001Brachytherapy RadioelementsNevada Prior Authorization List, Pg 159 Original policy
Q3027Injection, interferon beta-1a, 1 mcg for intramuscular useNevada Prior Authorization List, Pg 159 Original policy
Q3028Injection, interferon beta-1a, 1 mcg for subcutaneous useNevada Prior Authorization List, Pg 159 Original policy
Q4074Iloprost, Inhalation Solution, Fda-Approved Final Product, Non-Compounded, Administered Through Dme, Unit Dose Form, UpNevada Prior Authorization List, Pg 159 Original policy
Q4081INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS)Nevada Prior Authorization List, Pg 159 Original policy
Q4100Skin substitute, not otherwise specifiedNevada Prior Authorization List, Pg 159 Original policy
Q4101Apligraf, per square centimeter (add-on, list separately in addition to primary procedure)Nevada Prior Authorization List, Pg 159 Original policy
Q4102Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure)Nevada Prior Authorization List, Pg 159 Original policy
Q4103Oasis burn matrix, per square centimeter (add-on, list separately in addition to primary procedure)Nevada Prior Authorization List, Pg 159 Original policy
Q4104Integra bilayer matrix wound dressing (bmwd), per square centimeter (add-on, list separately in addition to primary procedure)Nevada Prior Authorization List, Pg 159 Original policy
Q4105Integra dermal regeneration template (drt) or integra omnigraft dermal regeneration matrix, per square centimeter (add-on, list separately in addition to primary procedure)Nevada Prior Authorization List, Pg 159 Original policy
Q4106Dermagraft, per square centimeterNevada Prior Authorization List, Pg 159 Original policy
Q4107Graftjacket, per square centimeter (add-on, list separately in addition to primary procedure)Nevada Prior Authorization List, Pg 159 Original policy
Q4108Integra matrix, per square centimeter (add-on, list separately in addition to primary procedure)Nevada Prior Authorization List, Pg 159 Original policy
Q4110Primatrix, per square centimeter (add-on, list separately in addition to primary procedure)Nevada Prior Authorization List, Pg 159 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

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