Anthem Blue Cross and Blue Shield Nevada prior authorization, page 80
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 |
|---|---|---|
| Q4166 | Cytal, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4167 | Truskin, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4169 | Artacent wound, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4170 | Cygnus, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4171 | Interfyl, 1 mg | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4173 | Palingen or palingen xplus, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4174 | Palingen or promatrx, 0.36 mg per 0.25 cc | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4175 | Miroderm, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4176 | Neopatch or therion, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4177 | FlowerAmnioFlo, 0.1 cc | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4178 | Floweramniopatch, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4179 | Flowerderm, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4180 | Revita, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4181 | Amnio wound, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4183 | Surgigraft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4184 | Cellesta or cellesta duo, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4185 | Cellesta Flowable Amnion (25 mg per cc); per 0.5 cc | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4186 | Epifix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4187 | Epicord, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4188 | Amnioarmor, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4189 | Artacent AC, 1 mg | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4190 | Artacent ac, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4191 | Restorigin, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4192 | Restorigin, 1 cc | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4193 | Coll-e-derm, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4194 | Novachor, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4195 | Puraply, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4196 | Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 161 Original policy |
| Q4197 | Puraply xt, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4198 | Genesis amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4199 | Cygnus matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4200 | Skin te, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4201 | Matrion, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4202 | Keroxx (2.5g/cc), 1cc | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4203 | Derma-gide, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4204 | Xwrap, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4205 | Membrane graft or membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4206 | Fluid flow or fluid GF, 1 cc | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4208 | Novafix, per square cenitmeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4209 | Surgraft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4210 | Axolotl graft or axolotl dualgraft, per square centimeter | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4211 | Amnion bio or axobiomembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4212 | Allogen, per cc | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4213 | Ascent, 0.5 mg | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4214 | Cellesta cord, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4215 | Axolotl ambient or axolotl cryo, 0.1 mg | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4216 | Artacent cord, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4217 | Woundfix, biowound, woundfix plus, biowound plus, woundfix xplus or biowound xplus, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4218 | Surgicord, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4219 | Surgigraft-dual, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |