Anthem Blue Cross and Blue Shield Nevada prior authorization code reference, page 81
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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 |
|---|---|---|
| Q4220 | Bellacell hd or surederm, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4221 | Amniowrap2, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4222 | Progenamatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4224 | Human health factor 10 amniotic patch (hhf10-p), per square centimeter (add- on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4225 | Amniobind or dermabind tl, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4226 | MyOwn skin, includes harvesting and preparation procedures, per square centimeter | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4227 | Amniocore, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4229 | Cogenex amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4230 | Cogenex Flowable Amnion, per 0.5 cc | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4232 | Corplex, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 162 Original policy |
| Q4233 | SurFactor or NuDyn, per 0.5 cc | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4234 | Xcellerate, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4235 | Amniorepair or altiply, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4236 | Carepatch, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4237 | Cryo-cord, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4238 | Derm-maxx, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4239 | Amnio-maxx or amnio-maxx lite, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4240 | CoreCyte, for topical use only, per 0.5 cc | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4241 | PolyCyte, for topical use only, per 0.5 cc | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4242 | AmnioCyte Plus, per 0.5 cc | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4245 | AmnioText, per cc | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4246 | CoreText or ProText, per cc | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4247 | Amniotext patch, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4248 | Dermacyte amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4249 | Amniply, for topical use only, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4250 | Amnioamp-mp, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4251 | Vim, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4252 | Vendaje, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4253 | Zenith amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4254 | Novafix dl, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4255 | Reguard, for topical use only, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4256 | Mlg-complete, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4257 | Relese, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4258 | Enverse, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4259 | Celera dual layer or celera dual membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4260 | Signature apatch, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4261 | Tag, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4262 | Dual layer impax membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4263 | Surgraft tl, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4264 | Cocoon membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4265 | Neostim tl, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4266 | Neostim membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 163 Original policy |
| Q4267 | Neostim dl, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4268 | Surgraft ft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4269 | Surgraft xt, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4270 | Complete sl, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4271 | Complete ft, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4272 | Esano a, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4273 | Esano aaa, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |
| Q4274 | Esano ac, per square centimeter (add-on, list separately in addition to primary procedure) | Nevada Prior Authorization List, Pg 164 Original policy |