Anthem Blue Cross and Blue Shield Nevada prior authorization, page 82
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 |
|---|---|---|
| Q4275 | Esano aca, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4276 | Orion, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4277 | Woundplus membrane or e-graft, per square centimeter | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4278 | Epieffect, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4279 | Vendaje ac, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4280 | Xcell amnio matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4281 | Barrera sl or barrera dl, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4282 | Cygnus dual, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4283 | Biovance tri-layer or biovance 3l, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4284 | Dermabind sl, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4285 | Nudyn dl or nudyn dl mesh, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4286 | Nudyn sl or nudyn slw, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4287 | Dermabind dl, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4288 | Dermabind ch, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4289 | Revoshield + amniotic barrier, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4290 | Membrane wrap-hydro, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4291 | Lamellas xt, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4292 | Lamellas, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4293 | Acesso dl, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4294 | Amnio quad-core, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4295 | Amnio tri-core amniotic, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4296 | Rebound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4297 | Emerge matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4298 | Amniocore pro, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4299 | Amniocore pro+, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4300 | Acesso tl, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4301 | Activate matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4302 | Complete aca, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4303 | Complete aa, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4304 | Grafix plus, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4305 | American amnion ac tri-layer, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4306 | American amnion ac, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4307 | American amnion, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4308 | Sanopellis, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4309 | Via matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4310 | Procenta, per 100 mg | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4311 | Acesso, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4312 | Acesso ac, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4313 | Dermabind fm, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4314 | Reeva ft, per square cenitmeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4315 | Regenelink amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4316 | Amchoplast, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4317 | Vitograft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4318 | E-graft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4319 | Sanograft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4320 | Pellograft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4321 | Renograft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4322 | Caregraft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4323 | Alloply, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4324 | Amniotx, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |