Anthem Blue Cross and Blue Shield Virginia policy
Modifiers 59 and XE, XP, XS, & XU: Distinct Procedural Service - Professional
Modifiers 59 and XE, XP, XS, & XU: Distinct Procedural Service - Professional is a public Anthem Blue Cross and Blue Shield Virginia policy (policy C-09006, effective Mar 1, 2025). It lists 113 CPT or HCPCS codes, 50 of them on the Anthem Blue Cross and Blue Shield Virginia prior authorization list. Not a coverage decision; the payer's own document governs.
View the original policy (PDF) ↗
- Policy number
- C-09006
- Effective
- Mar 1, 2025
- Line of business
- Commercial
- States
- VA
- 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 |
|---|---|---|---|
| 09006 | Not listed | Policies naming 09006 | |
| 20527 | Not listed | Policies naming 20527 | |
| 20550 | Not listed | Policies naming 20550 | |
| 20551 | Not listed | Policies naming 20551 | |
| 20552 | Not listed | Policies naming 20552 | |
| 20553 | Not listed | Policies naming 20553 | |
| 20560 | On the list | Needle insertion(s) without injection(s); 1 or 2 muscle(s) | Policies naming 20560 |
| 20561 | On the list | Needle insertion(s) without injection(s); 3 or more muscles | Policies naming 20561 |
| 20604 | Not listed | Policies naming 20604 | |
| 20606 | On the list | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound gu | Policies naming 20606 |
| 20611 | Not listed | Policies naming 20611 | |
| 43281 | On the list | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of me | Policies naming 43281 |
| 43282 | On the list | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh | Policies naming 43282 |
| 43283 | Not listed | Policies naming 43283 | |
| 43332 | On the list | Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis | Policies naming 43332 |
| 43333 | On the list | Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis | Policies naming 43333 |
| 43644 | On the list | Laparoscopy, Surg, Gastric Restrictive Procedure; W Gastric Bypass And Roux-En-Y Gastroenterostomy (Roux Limb <= 150 Cm) | Policies naming 43644 |
| 43645 | On the list | Laparoscopy, Surgical, Gastric Restrictive Procedure; With Gastric Bypass And Small Intestine Reconstruction | Policies naming 43645 |
| 43770 | On the list | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric ba | Policies naming 43770 |
| 43771 | On the list | Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only | Policies naming 43771 |
| 43772 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only | Policies naming 43772 |
| 43773 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device c | Policies naming 43773 |
| 43774 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous | Policies naming 43774 |
| 43775 | On the list | Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) | Policies naming 43775 |
| 43842 | On the list | Gastric Restrictive Proc, W/O Gastric Bypass, Morbid Obesity; Vertical-Banded Gastroplasty | Policies naming 43842 |
| 43843 | On the list | Gastric Restrictve Proc, W/O Gastric Bypass, Morbid Obesity; Non-Vertical-Banded Gastroplasty | Policies naming 43843 |
| 43845 | On the list | Gastric Stapling Morbid Obesity | Policies naming 43845 |
| 43846 | On the list | Gastric Restrictve Procedre, W/Gastric Bypass, Morbd Obsty; W/Short Limb Roux-En-Y Gastroenterostmy | Policies naming 43846 |
| 43847 | On the list | Gastric Restrictive Proc, W/Gastric Bypass, Morbid Obesity; W/Small Bowel Reconstruction | Policies naming 43847 |
| 43848 | On the list | Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (s | Policies naming 43848 |
| 43886 | On the list | Gastric restrictive procedure, open; revision of subcutaneous port component only | Policies naming 43886 |
| 43887 | On the list | Gastric restrictive procedure, open; removal of subcutaneous port component only | Policies naming 43887 |
| 43888 | On the list | Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only | Policies naming 43888 |
| 58140 | Not listed | Policies naming 58140 | |
| 58145 | On the list | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or | Policies naming 58145 |
| 58146 | Not listed | Policies naming 58146 | |
| 58545 | On the list | Laparoscopy, Surg, Myomectomy; 1-4 Intramural Myomas, Total Wt 250 Gms, &/Or Remove Surface Myomas | Policies naming 58545 |
| 58546 | On the list | Laparoscopy, Surg, Myomectomy; 5/> Intramural Myomas &/Or Total Wt >250 Gms | Policies naming 58546 |
| 58561 | Not listed | Policies naming 58561 | |
| 58570 | On the list | Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less | Policies naming 58570 |
| 58571 | On the list | Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less;with removal of tube(s) and/or ovary (s) | Policies naming 58571 |
| 58572 | On the list | Laparoscopy; surgical, with total hysterectomy, for uterus greater than 250 g | Policies naming 58572 |
| 58573 | On the list | Laparoscopy; surgical, with total hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary (s) | Policies naming 58573 |
| 63650 | On the list | Percutaneous Implantation, Neurostimulator Electrode Array, Epidural | Policies naming 63650 |
| 63655 | On the list | Laminectomy, Implantation, Neurostimulator Electrodes, Plate/Paddle, Epidural | Policies naming 63655 |
| 64486 | Not listed | Policies naming 64486 | |
| 64487 | Not listed | Policies naming 64487 | |
| 64488 | Not listed | Policies naming 64488 | |
| 64489 | Not listed | Policies naming 64489 | |
| 76512 | Not listed | Policies naming 76512 | |
| 76604 | Not listed | Policies naming 76604 | |
| 76700 | Not listed | Policies naming 76700 | |
| 76706 | Not listed | Policies naming 76706 | |
| 76770 | Not listed | Policies naming 76770 | |
| 76776 | Not listed | Policies naming 76776 | |
| 76815 | Not listed | Policies naming 76815 | |
| 76857 | Not listed | Policies naming 76857 | |
| 76881 | Not listed | Policies naming 76881 | |
| 76882 | Not listed | Policies naming 76882 | |
| 76942 | Not listed | Policies naming 76942 | |
| 78265 | Not listed | Policies naming 78265 | |
| 78830 | Not listed | Policies naming 78830 | |
| 78835 | Not listed | Policies naming 78835 | |
| 80305 | Not listed | Policies naming 80305 | |
| 80307 | Not listed | Policies naming 80307 | |
| 80320 | Not listed | Policies naming 80320 | |
| 80377 | Not listed | Policies naming 80377 | |
| 81000 | On the list | Urinalysis, Dip Stick/Tablet Reagent; Non-Automated W/Microscopy | Policies naming 81000 |
| 81003 | On the list | Urinalysis, Dip Stick/Tablet Reagent; Automated, W/O Microscopy | Policies naming 81003 |
| 81005 | On the list | Urinalysis; Qualitative/Semiquantitative, Except Immunoassays | Policies naming 81005 |
| 82542 | On the list | Column Chromatography/Mass Spectrometry; Quantitative, Single Stationary & Mobile Phase | Policies naming 82542 |
| 82570 | On the list | Creatinine; Other Source | Policies naming 82570 |
| 83516 | On the list | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitativ | Policies naming 83516 |
| 83520 | On the list | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise sp | Policies naming 83520 |
| 83789 | Not listed | Policies naming 83789 | |
| 83986 | On the list | pH; body fluid, not otherwise specified | Policies naming 83986 |
| 83992 | On the list | Phencyclidine (Pcp) | Policies naming 83992 |
| 84156 | On the list | Protein, Total, Except By Refractometry; Urine | Policies naming 84156 |
| 84311 | On the list | Spectrophotometry, Analyte Not Elsewhere Specified | Policies naming 84311 |
| 95700 | Not listed | Policies naming 95700 | |
| 95950 | Not listed | Policies naming 95950 | |
| 95953 | Not listed | Policies naming 95953 | |
| 95956 | Not listed | Policies naming 95956 | |
| 95957 | Not listed | Policies naming 95957 | |
| 96365 | On the list | Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour | Policies naming 96365 |
| 96369 | Not listed | Policies naming 96369 | |
| 96372 | On the list | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular | Policies naming 96372 |
| 96373 | Not listed | Policies naming 96373 | |
| 96374 | Not listed | Policies naming 96374 | |
| 96379 | Not listed | Policies naming 96379 | |
| 99281 | Not listed | Policies naming 99281 | |
| 99282 | Not listed | Policies naming 99282 | |
| 99283 | Not listed | Policies naming 99283 | |
| 99284 | Not listed | Policies naming 99284 | |
| 99285 | Not listed | Policies naming 99285 | |
| A4221 | Not listed | Policies naming A4221 | |
| A4222 | Not listed | Policies naming A4222 | |
| E0776 | Not listed | Policies naming E0776 | |
| E0781 | Not listed | Policies naming E0781 | |
| G0138 | Not listed | Policies naming G0138 | |
| G0480 | Not listed | Policies naming G0480 | |
| G0483 | Not listed | Policies naming G0483 | |
| G0659 | Not listed | Policies naming G0659 | |
| J1202 | Not listed | Policies naming J1202 | |
| J2001 | Not listed | Policies naming J2001 | |
| L8679 | On the list | Implantable neurostimulator, pulse generator, any type | Policies naming L8679 |
| L8680 | On the list | Implantable neurostimulator electrode, each | Policies naming L8680 |
| L8687 | On the list | Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension | Policies naming L8687 |
| Q3014 | Not listed | Policies naming Q3014 | |
| S9339 | Not listed | Policies naming S9339 | |
| S9349 | Not listed | Policies naming S9349 | |
| S9355 | Not listed | Policies naming S9355 | |
| S9810 | On the list | Home therapy; professional pharmacy service for provision of infusion, specialty drug administration, and/or disease sta | Policies naming S9810 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list