Anthem Blue Cross and Blue Shield Virginia policy
CG-MED-89 Home Parenteral Nutrition
CG-MED-89 Home Parenteral Nutrition is a public Anthem Blue Cross and Blue Shield Virginia policy (policy CG-MED-89). It lists 27 CPT or HCPCS codes, 25 of them on the Anthem Blue Cross and Blue Shield Virginia prior authorization list. Not a coverage decision; the payer's own document governs.
- Policy number
- CG-MED-89
- 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 Virginia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield Virginia policies |
|---|---|---|---|
| B4164 | On the list | Parenteral 50% Dextrose Solu | Policies naming B4164 |
| B4168 | On the list | Parenteral Sol Amino Acid 3. | Policies naming B4168 |
| B4172 | Not listed | Policies naming B4172 | |
| B4176 | On the list | Parenteral Sol Amino Acid 7 | Policies naming B4176 |
| B4178 | On the list | Parenteral Sol Amino Acid > | Policies naming B4178 |
| B4180 | On the list | Parenteral Sol Carb > 50% | Policies naming B4180 |
| B4185 | On the list | Parenteral nutrition solution, not otherwise specified, 10 grams lipids | Policies naming B4185 |
| B4187 | On the list | Omegaven, 10 g lipids | Policies naming B4187 |
| B4189 | On the list | Parenteral Sol Amino Acid & | Policies naming B4189 |
| B4193 | On the list | Parenteral Sol 52-73 Gm Prot | Policies naming B4193 |
| B4197 | On the list | Parenteral Sol 74-100 Gm Pro | Policies naming B4197 |
| B4199 | On the list | Parenteral Sol > 100gm Prote | Policies naming B4199 |
| B4216 | On the list | Parenteral Nutrition Additiv | Policies naming B4216 |
| B4220 | On the list | Parenteral Supply Kit Premix | Policies naming B4220 |
| B4222 | On the list | Parenteral Supply Kit Homemi | Policies naming B4222 |
| B4224 | On the list | Parenteral Administration Ki | Policies naming B4224 |
| B5000 | On the list | Parenteral Sol Renal-Amirosy | Policies naming B5000 |
| B5100 | On the list | Parenteral Sol Hepatic-Fream | Policies naming B5100 |
| B5200 | On the list | Parenteral Sol Stres-Brnch C | Policies naming B5200 |
| B9004 | On the list | Parenteral Infus Pump Portab | Policies naming B9004 |
| B9006 | On the list | Parenteral Infus Pump Statio | Policies naming B9006 |
| B9999 | Not listed | Policies naming B9999 | |
| S9364 | On the list | Home infusion therapy, total parenteral nutrition (TPN) (do not use with home infusion codes S9365-S9368 using daily vol | Policies naming S9364 |
| S9365 | On the list | Home infusion therapy, total parenteral nutrition (TPN); one liter per day | Policies naming S9365 |
| S9366 | On the list | Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two liters per day | Policies naming S9366 |
| S9367 | On the list | Home infusion therapy, total parenteral nutrition (TPN); more than two liter but no more than three liters per day | Policies naming S9367 |
| S9368 | On the list | Home infusion therapy, total parenteral nutrition (TPN); more than three liter per day | Policies naming S9368 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list