Anthem Blue Cross and Blue Shield Nevada prior authorization, page 9
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 |
|---|---|---|
| 22860 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (List separa | Nevada Prior Authorization List, Pg 19 Original policy |
| 22861 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervi | Nevada Prior Authorization List, Pg 19 Original policy |
| 22862 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumba | Nevada Prior Authorization List, Pg 19 Original policy |
| 22864 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical | Nevada Prior Authorization List, Pg 20 Original policy |
| 22865 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar | Nevada Prior Authorization List, Pg 20 Original policy |
| 22867 | Insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; sin | Nevada Prior Authorization List, Pg 20 Original policy |
| 22868 | Insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; sec | Nevada Prior Authorization List, Pg 20 Original policy |
| 22869 | Insertion of interlaminar/interspinous process stabilization/ distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single | Nevada Prior Authorization List, Pg 20 Original policy |
| 22870 | Insertion of interlaminar/interspinous process stabilization/ distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second | Nevada Prior Authorization List, Pg 20 Original policy |
| 22900 | Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); less than 5 cm | Nevada Prior Authorization List, Pg 20 Original policy |
| 22901 | Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); 5 cm or greater | Nevada Prior Authorization List, Pg 20 Original policy |
| 22902 | Excision, tumor, soft tissue of abdominal wall, subcutaneous; less than 3 cm | Nevada Prior Authorization List, Pg 20 Original policy |
| 22903 | Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm or greater | Nevada Prior Authorization List, Pg 20 Original policy |
| 23030 | Incision & Drainage, Shoulder Area; Deep Abscess/Hematoma | Nevada Prior Authorization List, Pg 20 Original policy |
| 23071 | Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater | Nevada Prior Authorization List, Pg 20 Original policy |
| 23075 | Excision, tumor, soft tissue of shoulder area, subcutaneous; less than 3 cm | Nevada Prior Authorization List, Pg 20 Original policy |
| 23076 | Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); less than 5 cm | Nevada Prior Authorization List, Pg 20 Original policy |
| 23105 | Arthrotomy; Glenohumeral Joint, W/Synovectomy, W/Wo Bx | Nevada Prior Authorization List, Pg 20 Original policy |
| 23107 | Arthrotomy, Glenohumeral Joint, W/Exploration, W/Wo Loose/Fb Removal | Nevada Prior Authorization List, Pg 20 Original policy |
| 23120 | Claviculectomy; Partial | Nevada Prior Authorization List, Pg 20 Original policy |
| 23130 | Acromioplasty/Acromionectomy, Partial, W/Wo Coracoacromial Ligament Release | Nevada Prior Authorization List, Pg 20 Original policy |
| 23140 | Excision/Curettage, Bone Cyst/Benign Tumor, Clavicle/Scapula | Nevada Prior Authorization List, Pg 20 Original policy |
| 23410 | Repair, Ruptured Musculotendinous Cuff, Open; Acute | Nevada Prior Authorization List, Pg 20 Original policy |
| 23412 | Repair, Ruptured Musculotendinous Cuff; Chronic | Nevada Prior Authorization List, Pg 20 Original policy |
| 23415 | Coracoacromial Ligament Release, W/Wo Acromioplasty | Nevada Prior Authorization List, Pg 20 Original policy |
| 23420 | Reconstruction, Complete Shoulder (Rotator) Cuff Avulsion, Chronic (Includes Acromioplasty) | Nevada Prior Authorization List, Pg 21 Original policy |
| 23430 | Tenodesis, Long Tendon, Biceps | Nevada Prior Authorization List, Pg 21 Original policy |
| 23440 | Resection/Transplantation, Long Tendon, Biceps | Nevada Prior Authorization List, Pg 21 Original policy |
| 23450 | Capsulorrhaphy, Anterior; Putti-Platt Proc/Magnuson Type Operation | Nevada Prior Authorization List, Pg 21 Original policy |
| 23455 | Capsulorrhaphy, Anterior; W/Labral Repair | Nevada Prior Authorization List, Pg 21 Original policy |
| 23460 | Capsulorrhaphy, Anterior, Any Type; W/Bone Block | Nevada Prior Authorization List, Pg 21 Original policy |
| 23462 | Capsulorrhaphy, Anterior, Any Type; W/Coracoid Process Transfer | Nevada Prior Authorization List, Pg 21 Original policy |
| 23465 | Capsulorrhaphy, Glenohumeral Joint, Posterior, W/Wo Bone Block | Nevada Prior Authorization List, Pg 21 Original policy |
| 23466 | Capsulorrhaphy, Glenohumeral Joint, Any Type Multi-Directional Instability | Nevada Prior Authorization List, Pg 21 Original policy |
| 23470 | Arthroplasty, Glenohumeral Joint; Hemiarthroplasty | Nevada Prior Authorization List, Pg 21 Original policy |
| 23472 | Arthroplasty, Glenohumeral Joint; Total Shoulder | Nevada Prior Authorization List, Pg 21 Original policy |
| 23473 | Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component | Nevada Prior Authorization List, Pg 21 Original policy |
| 23474 | Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component | Nevada Prior Authorization List, Pg 21 Original policy |
| 23700 | Manipulation W/Anesthesia, Shoulder Joint, W/Application Of Fixation Apparatus (Excl Dislocation) | Nevada Prior Authorization List, Pg 21 Original policy |
| 24066 | Bx, Soft Tissue, Upper Arm/Elbow Area; Deep (Subfascial/Im) | Nevada Prior Authorization List, Pg 21 Original policy |
| 24071 | Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater | Nevada Prior Authorization List, Pg 21 Original policy |
| 24073 | Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); 5 cm or greater | Nevada Prior Authorization List, Pg 21 Original policy |
| 24075 | Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; less than 3 cm | Nevada Prior Authorization List, Pg 21 Original policy |
| 24076 | Radical resection of tumor (eg, malignant neoplasm), soft tissue of upper arm or elbow area; less than 5 cm | Nevada Prior Authorization List, Pg 22 Original policy |
| 24101 | Arthrotomy, Elbow; W/Joint Exploration, W/Wo Bx, W/Wo Removal Loose/Fb | Nevada Prior Authorization List, Pg 22 Original policy |
| 24102 | Arthrotomy, Elbow; W/Synovectomy | Nevada Prior Authorization List, Pg 22 Original policy |
| 24105 | Excision, Olecranon Bursa | Nevada Prior Authorization List, Pg 22 Original policy |
| 24110 | Excision/Curettage, Bone Cyst/Benign Tumor, Humerus | Nevada Prior Authorization List, Pg 22 Original policy |
| 24120 | Excision/Curettage, Bone Cyst/Benign Tumor, Head/Neck, Radius/Olecranon | Nevada Prior Authorization List, Pg 22 Original policy |
| 24130 | Excision, Radial Head | Nevada Prior Authorization List, Pg 22 Original policy |