Anthem Blue Cross and Blue Shield Nevada policy
CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery
CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery is a public Anthem Blue Cross and Blue Shield Nevada policy (policy CG-SURG-84). It lists 45 CPT or HCPCS codes, 44 of them on the Anthem Blue Cross and Blue Shield Nevada prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-SURG-84
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross and Blue Shield Nevada prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield Nevada policies |
|---|---|---|---|
| 00129 | Not listed | Policies naming 00129 | |
| 21120 | On the list | Genioplasty; Augmentation (Autograft, Allograft, Prosthetic Matl) | Policies naming 21120 |
| 21121 | On the list | Genioplasty; Sliding Osteotomy, Single Piece | Policies naming 21121 |
| 21122 | On the list | Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin | Policies naming 21122 |
| 21123 | On the list | Genioplasty; Sliding, Augmentation W/Interpositional Bone Grafts W/Obtaining Autograft | Policies naming 21123 |
| 21125 | On the list | Augmentation, Mandibular Body/Angle; Prosthetic Matl | Policies naming 21125 |
| 21127 | On the list | Augmentation, Mandibular Body/Angle; W/Bone Graft/Onlay/Interpositional W/Obtaining Autograft | Policies naming 21127 |
| 21141 | On the list | Reconstruction Midface, Lefort I; 1 Piece, W/O Bone Graft | Policies naming 21141 |
| 21142 | On the list | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft | Policies naming 21142 |
| 21143 | On the list | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft | Policies naming 21143 |
| 21145 | On the list | Reconstruction Midface, Lefort I; 1 Piece, W/Bone Grafts | Policies naming 21145 |
| 21146 | On the list | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining | Policies naming 21146 |
| 21147 | On the list | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes o | Policies naming 21147 |
| 21150 | On the list | Reconstruction Midface, Lefort Ii; Anterior Intrusion | Policies naming 21150 |
| 21151 | On the list | Reconstruction Midface, Lefort Ii; W/Bone Grafts | Policies naming 21151 |
| 21154 | On the list | Reconstruction Midface, Lefort Iii, W/Bone Grafts; W/O Lefort I | Policies naming 21154 |
| 21155 | On the list | Reconstruction Midface, Lefort Iii, W/Bone Grafts; W/Lefort I | Policies naming 21155 |
| 21188 | On the list | Reconstruction, Midface, Osteotomies (Non-Lefort Type), W/Grafts, W/Obtaining Autografts | Policies naming 21188 |
| 21193 | On the list | Reconstruction, Mandibular Rami, Horizontal, Vertical, "C"/"L" Osteotomy; W/O Bone Graft | Policies naming 21193 |
| 21194 | On the list | Reconstruction, Mandibular Rami, Horizontal, Vertical, "C"/"L" Osteotomy; W/Bone Graft | Policies naming 21194 |
| 21195 | On the list | Reconstruction, Mandibular Rami &/Or Body, Sagittal Split; W/O Int Rigid Fixation | Policies naming 21195 |
| 21196 | On the list | Reconstruction, Mandibular Rami &/Or Body, Sagittal Split; W/Int Rigid Fixation | Policies naming 21196 |
| 21198 | On the list | Osteotomy, Mandible, Segmental | Policies naming 21198 |
| 21199 | On the list | Osteotomy, Mandible, Segmental; W/Genioglossus Advancement | Policies naming 21199 |
| 21206 | On the list | Osteotomy, Maxilla, Segmental | Policies naming 21206 |
| 21208 | On the list | Osteoplasty, Facial Bones; Augmentation (Autograft, Allograft/Prosthetic Implant) | Policies naming 21208 |
| 21209 | On the list | Osteoplasty, Facial Bones; Reduction | Policies naming 21209 |
| 21210 | On the list | Graft, Bone; Nasal, Maxillary/Malar Areas (Includes Obtaining Graft) | Policies naming 21210 |
| 21215 | On the list | Graft, Bone; Mandible (Includes Obtaining Graft) | Policies naming 21215 |
| 21244 | On the list | Reconstruction, Mandible, Extraoral, W/Transosteal Bone Plate | Policies naming 21244 |
| 21245 | On the list | Reconstruction, Mandible/Maxilla, Subperiosteal Implant; Partial | Policies naming 21245 |
| 21246 | On the list | Reconstruction, Mandible/Maxilla, Subperiosteal Implant; Complete | Policies naming 21246 |
| 21247 | On the list | Reconstruction, Mandibular Condyle W/Bone & Cartilage Autografts | Policies naming 21247 |
| D7940 | On the list | osteoplasty - for orthognathic deformities | Policies naming D7940 |
| D7941 | On the list | osteotomy - mandibular rami | Policies naming D7941 |
| D7943 | On the list | osteotomy - mandibular rami with bone graft; includes obtaining the graft | Policies naming D7943 |
| D7944 | On the list | osteotomy - segmented or subapical | Policies naming D7944 |
| D7945 | On the list | osteotomy - body of mandible | Policies naming D7945 |
| D7946 | On the list | LeFort I (maxilla - total) | Policies naming D7946 |
| D7947 | On the list | LeFort I (maxilla - segmented) | Policies naming D7947 |
| D7948 | On the list | LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft | Policies naming D7948 |
| D7949 | On the list | LeFort II or LeFort III - with bone graft | Policies naming D7949 |
| D7950 | On the list | osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report | Policies naming D7950 |
| D7995 | On the list | synthetic graft - mandible or facial bones, by report | Policies naming D7995 |
| D7996 | On the list | implant-mandible for augmentation purposes (excluding alveolar ridge), by report | Policies naming D7996 |
All Anthem Blue Cross and Blue Shield Nevada policies · Anthem Blue Cross and Blue Shield Nevada prior authorization CPT list