Anthem Blue Cross and Blue Shield Nevada prior authorization, page 8
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 |
|---|---|---|
| 22514 | 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 |
| 22515 | 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 |
| 22526 | Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single le | Nevada Prior Authorization List, Pg 16 Original policy |
| 22527 | Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral, including fluoroscopic guidance; 1 or mor | Nevada Prior Authorization List, Pg 16 Original policy |
| 22532 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic | Nevada Prior Authorization List, Pg 16 Original policy |
| 22533 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | Nevada Prior Authorization List, Pg 16 Original policy |
| 22534 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral | Nevada Prior Authorization List, Pg 16 Original policy |
| 22548 | Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process | Nevada Prior Authorization List, Pg 16 Original policy |
| 22551 | Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 | Nevada Prior Authorization List, Pg 17 Original policy |
| 22552 | Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each add | Nevada Prior Authorization List, Pg 17 Original policy |
| 22554 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 | Nevada Prior Authorization List, Pg 17 Original policy |
| 22556 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic | Nevada Prior Authorization List, Pg 17 Original policy |
| 22558 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | Nevada Prior Authorization List, Pg 17 Original policy |
| 22585 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in ad | Nevada Prior Authorization List, Pg 17 Original policy |
| 22586 | Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when perfor | Nevada Prior Authorization List, Pg 17 Original policy |
| 22590 | Arthrodesis, posterior technique, craniocervical (occiput-C2) | Nevada Prior Authorization List, Pg 17 Original policy |
| 22595 | Arthrodesis, posterior technique, atlas-axis (C1-C2) | Nevada Prior Authorization List, Pg 17 Original policy |
| 22600 | Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment | Nevada Prior Authorization List, Pg 17 Original policy |
| 22610 | Arthrodesis, posterior or posterolateral technique, single interspace; thoracic (with lateral transverse technique, when performed) | Nevada Prior Authorization List, Pg 17 Original policy |
| 22612 | Arthrodesis, posterior or posterolateral technique, single interspace; lumbar (with lateral transverse technique, when performed) | Nevada Prior Authorization List, Pg 17 Original policy |
| 22614 | Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (List separately in addition to code for primary procedure) | Nevada Prior Authorization List, Pg 17 Original policy |
| 22630 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar | Nevada Prior Authorization List, Pg 17 Original policy |
| 22632 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional in | Nevada Prior Authorization List, Pg 18 Original policy |
| 22633 | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other | Nevada Prior Authorization List, Pg 18 Original policy |
| 22634 | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other | Nevada Prior Authorization List, Pg 18 Original policy |
| 22800 | Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments | Nevada Prior Authorization List, Pg 18 Original policy |
| 22802 | Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments | Nevada Prior Authorization List, Pg 18 Original policy |
| 22804 | Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments | Nevada Prior Authorization List, Pg 18 Original policy |
| 22808 | Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments | Nevada Prior Authorization List, Pg 18 Original policy |
| 22810 | Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments | Nevada Prior Authorization List, Pg 18 Original policy |
| 22812 | Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments | Nevada Prior Authorization List, Pg 18 Original policy |
| 22818 | Kyphectomy, Exposure Of Spine & Resection Vertebral Segments; 1-2 Segs | Nevada Prior Authorization List, Pg 18 Original policy |
| 22819 | Kyphectomy, Exposure Of Spine & Resection Vertebral Segments; 3 / More | Nevada Prior Authorization List, Pg 18 Original policy |
| 22830 | Exploration of Spinal Fusion | Nevada Prior Authorization List, Pg 18 Original policy |
| 22840 | Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across one interspace, atlantoax | Nevada Prior Authorization List, Pg 18 Original policy |
| 22841 | Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) | Nevada Prior Authorization List, Pg 18 Original policy |
| 22842 | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 v | Nevada Prior Authorization List, Pg 18 Original policy |
| 22843 | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 | Nevada Prior Authorization List, Pg 19 Original policy |
| 22844 | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or mo | Nevada Prior Authorization List, Pg 19 Original policy |
| 22845 | Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) | Nevada Prior Authorization List, Pg 19 Original policy |
| 22846 | Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) | Nevada Prior Authorization List, Pg 19 Original policy |
| 22847 | Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure) | Nevada Prior Authorization List, Pg 19 Original policy |
| 22848 | Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separate | Nevada Prior Authorization List, Pg 19 Original policy |
| 22849 | Reinsertion, Spinal Fixation Device | Nevada Prior Authorization List, Pg 19 Original policy |
| 22853 | Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g. screws, flanges), when performed, t | Nevada Prior Authorization List, Pg 19 Original policy |
| 22854 | Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g. screws, flanges), when performed, t | Nevada Prior Authorization List, Pg 19 Original policy |
| 22856 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompres | Nevada Prior Authorization List, Pg 19 Original policy |
| 22857 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); single interspace, lumbar | Nevada Prior Authorization List, Pg 19 Original policy |
| 22858 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompres | Nevada Prior Authorization List, Pg 19 Original policy |
| 22859 | Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methlmethacrylate) to intervertebral disc space or verebral body defect without interbody arthro | Nevada Prior Authorization List, Pg 19 Original policy |