Anthem Blue Cross and Blue Shield Nevada prior authorization, page 79
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 |
|---|---|---|
| Q4111 | Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4112 | Cymetra, injectable, 1cc | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4113 | GRAFTJACKET XPRESS, injectable, 1cc | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4114 | Integra flowable wound matrix, injectable, 1 cc | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4115 | Alloskin, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4116 | Alloderm, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4117 | Hyalomatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4118 | Matristem micromatrix, 1 mg | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4121 | Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4122 | Dermacell, dermacell awm or dermacell awm porous, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4123 | Alloskin rt, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4124 | Oasis ultra tri-layer wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4125 | Arthroflex, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4126 | Memoderm, dermaspan, tranzgraft or integuply, per square centimeter (add- on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4127 | Talymed, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 159 Original policy |
| Q4128 | Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4130 | Strattice tm, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4132 | Grafix core and grafixpl core, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4133 | Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add- on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4134 | Hmatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4135 | Mediskin, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4136 | Ez-derm, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4137 | Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4138 | Biodfence dryflex, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4139 | Amniomatrix or biodmatrix, injectable, 1 cc | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4140 | Biodfence, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4141 | Alloskin ac, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4142 | Xcm biologic tissue matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4143 | Repriza, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4145 | Epifix, injectable, 1 mg | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4146 | Tensix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4147 | Architect, architect px, or architect fx, extracellular matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4148 | Neox cord 1k, neox cord rt, or clarix cord 1k, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4149 | Excellagen, 0.1 cc | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4150 | Allowrap ds or dry, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4151 | Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4152 | Dermapure, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4153 | Dermavest and plurivest, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4154 | Biovance, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4155 | Neoxflo or clarixflo, 1 mg | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4156 | Neox 100 or clarix 100, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4157 | Revitalon, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4158 | Kerecis omega3, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4159 | Affinity, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4160 | Nushield, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4161 | Bio-connekt wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 160 Original policy |
| Q4162 | WoundEx Flow, BioSkin Flow, 0.5 cc | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4163 | Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4164 | Helicoll, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4165 | Keramatrix or kerasorb, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |