Anthem Blue Cross and Blue Shield Nevada prior authorization code reference, page 76
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Source code lookup
Each row links an imported source code to its service or category label. Check the original document for the complete plan scope, review type and qualifications.
Source code index
| Code | Description | Source |
|---|---|---|
| J9331 | Injection, sirolimus protein-bound particles, 1 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9332 | Injection, efgartigimod alfa-fcab, 2mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9333 | Injection, rozanolixizumab-noli, 1 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9334 | Injection, efgartigimod alfa, 2 mg and hyaluronidase-qvfc | Nevada Prior Authorization List, Pg 154 Original policy |
| J9345 | Injection, retifanlimab-dlwr, 1 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9347 | Injection, tremelimumab-actl, 1 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9348 | Injection, naxitamab-gqgk, 1 m | Nevada Prior Authorization List, Pg 154 Original policy |
| J9349 | Injection, tafasitamab-cxix, 2 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9350 | Injection, mosunetuzumab-axgb, 1 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9353 | Injection, margetuximab-cmkb, 5 m | Nevada Prior Authorization List, Pg 154 Original policy |
| J9354 | Injection, ado-trastuzumab emtansine, 1 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9358 | Injection, fam-trastuzumab deruxtecan-nxki, 1 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9359 | Injection, loncastuximab tesirine-lpyl, 0.075 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9361 | Injection, efbemalenograstim alfa-vuxw, 0.5 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9376 | Injection, pozelimab-bbfg, 1 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9380 | Injection, teclistamab-cqyv, 0.5 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9381 | Injection, teplizumab-mzwv, 5 mcg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9382 | Injection, zenocutuzumab-zbco, 1 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9400 | Injection, ziv-aflibercept, 1 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| J9601 | Injection, linvoseltamab-gcpt, 1 mg | Nevada Prior Authorization List, Pg 154 Original policy |
| K0010 | Stnd Wt Frame Power Whlchr | Nevada Prior Authorization List, Pg 154 Original policy |
| K0011 | Stnd Wt Pwr Whlchr W Control | Nevada Prior Authorization List, Pg 154 Original policy |
| K0012 | Ltwt Portbl Power Whlchr | Nevada Prior Authorization List, Pg 154 Original policy |
| K0013 | Custom motorized/power wheelchair base | Nevada Prior Authorization List, Pg 154 Original policy |
| K0014 | Other Power Whlchr Base | Nevada Prior Authorization List, Pg 154 Original policy |
| K0800 | POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS | Nevada Prior Authorization List, Pg 154 Original policy |
| K0801 | POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY, 301 TO 450 POUNDS | Nevada Prior Authorization List, Pg 154 Original policy |
| K0802 | POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS | Nevada Prior Authorization List, Pg 154 Original policy |
| K0806 | POWER OPERATED VEHICLE, GROUP 2 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS | Nevada Prior Authorization List, Pg 154 Original policy |
| K0807 | POWER OPERATED VEHICLE, GROUP 2 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS | Nevada Prior Authorization List, Pg 154 Original policy |
| K0808 | POWER OPERATED VEHICLE, GROUP 2 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS | Nevada Prior Authorization List, Pg 154 Original policy |
| K0812 | POWER OPERATED VEHICLE, NOT OTHERWISE CLASSIFIED | Nevada Prior Authorization List, Pg 154 Original policy |
| K0813 | POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 | Nevada Prior Authorization List, Pg 154 Original policy |
| K0814 | POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS | Nevada Prior Authorization List, Pg 154 Original policy |
| K0815 | POWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS | Nevada Prior Authorization List, Pg 154 Original policy |
| K0816 | POWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACTIY UP TO AND INCLUDING 300 POUNDS | Nevada Prior Authorization List, Pg 154 Original policy |
| K0820 | POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POU | Nevada Prior Authorization List, Pg 155 Original policy |
| K0821 | POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0822 | POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0823 | POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0824 | POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0825 | POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0826 | POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0827 | POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS | Nevada Prior Authorization List, Pg 155 Original policy |
| K0828 | POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE | Nevada Prior Authorization List, Pg 155 Original policy |
| K0829 | POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE | Nevada Prior Authorization List, Pg 155 Original policy |
| K0830 | POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 30 | Nevada Prior Authorization List, Pg 155 Original policy |
| K0831 | POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUND | Nevada Prior Authorization List, Pg 155 Original policy |
| K0835 | POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUD | Nevada Prior Authorization List, Pg 155 Original policy |
| K0836 | POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 | Nevada Prior Authorization List, Pg 155 Original policy |