Anthem Blue Cross and Blue Shield Nevada prior authorization, page 83
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 |
|---|---|---|
| Q4325 | Acapatch, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4326 | Woundplus, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4327 | Duoamnion, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4328 | Most, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4329 | Singlay, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4330 | Total, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4331 | Axolotl graft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 165 Original policy |
| Q4332 | Axolotl dualgraft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4333 | Ardeograft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4334 | Amnioplast 1, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4335 | Amnioplast 2, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4336 | Artacent c, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4337 | Artacent trident, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4338 | Artacent velos, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4339 | Artacent vericlen, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4340 | Simpligraft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4341 | Simplimax, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4342 | Theramend, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4343 | Dermacyte ac matrix amniotic membrane allograft, per square centimeter (add- on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4344 | Tri-membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4345 | Matrix hd allograft dermis, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4346 | Shelter dm matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4347 | Rampart dl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4348 | Sentry sl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4349 | Mantle dl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4350 | Palisade dm matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4351 | Enclose tl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4352 | Overlay sl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4353 | Xceed tl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4354 | Palingen dual-layer membrane and dual-layer palingen x-membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4355 | Abiomend xplus membrane and abiomend xplus hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4356 | Abiomend membrane and abiomend hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4357 | Xwrap plus, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4358 | Xwrap dual, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4359 | Choriply, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4360 | Amchoplast fd, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4361 | Epixpress, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 166 Original policy |
| Q4362 | Cygnus disk, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 167 Original policy |
| Q4363 | Amnio burgeon membrane and hydromembrane, per square centimeter (add- on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 167 Original policy |
| Q4364 | Amnio burgeon xplus membrane and xplus hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 167 Original policy |
| Q4365 | Amnio burgeon dual-layer membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 167 Original policy |
| Q4366 | Dual layer amnio burgeon x-membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 167 Original policy |
| Q4367 | Amniocore sl, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 167 Original policy |
| Q4369 | Amnioplast 3, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 167 Original policy |
| Q5098 | Injection, ustekinumab-srlf (imuldosa), biosimilar, 1 mg | Nevada Prior Authorization List, Pg 167 Original policy |
| Q5099 | Injection, ustekinumab-stba (steqeyma), biosimilar, 1 mg | Nevada Prior Authorization List, Pg 167 Original policy |
| Q5100 | Injection, ustekinumab-kfce (yesintek), biosimilar, 1 mg | Nevada Prior Authorization List, Pg 167 Original policy |
| Q5101 | Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram | Nevada Prior Authorization List, Pg 167 Original policy |
| Q5103 | Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg | Nevada Prior Authorization List, Pg 167 Original policy |
| Q5104 | Injection, infliximab-abda, biosimilar, (renflexis), 10 mg | Nevada Prior Authorization List, Pg 167 Original policy |