Nevada
Provider Communications
Prior authorization requirements for the below codes
Prior authorization requirements will be added for the following codes:
- 15771 - Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
- 15772 - Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure.)
- 15773 - Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate
- 15774 - Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure.)
- 31574 - Laryngoscopy, flexible; with injection(s) for augmentation (for example, percutaneous, transoral), unilateral
- 0378T - Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional
- 0379T - Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional
- C9122 - Mometasone furoate sinus implant, 10 mcg (Sinuva)
- 11950 - Subcutaneous injection of filling material (for example, collagen); 1 cc or less
- 11951 - Subcutaneous injection of filling material (for example, collagen); 1.1 to 5.0 cc
- 11952 - Subcutaneous injection of filling material (for example, collagen); 5.1 to 10.0 cc
- 11954 - Subcutaneous injection of filling material (for example, collagen); over 10.0 cc
- 0565T - Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation
- 0566T - Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral
- C1878 - Material for vocal cord medialization, synthetic (implantable)
- G0429 - Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (for example, as a result of highly active antiretroviral therapy)
- L8607 - Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies
- Q2026 - Injection, Radiesse, 0.1 ml
- Q2028 - Injection, sculptra, 0.5 mg
- 0489T - Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cells
- 0490T - Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands
- 0202U - Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
- 17999 - Unlisted procedure, skin, mucous membrane and subcutaneous tissue
- 46999 - Unlisted procedure, anus
Not all prior authorization requirements are listed here. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com at https://www.anthem.com/provider/medicare-advantage > Login. Contracted and noncontracted providers who are unable to access Availity* may call the number on the back of the member’s ID card.
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October 2020 Anthem Provider News and Important Updates -- Nevada