Anthem Blue Cross and Blue Shield Virginia policy
SURG.00155 Cryosurgery of Peripheral Nerves
SURG.00155 Cryosurgery of Peripheral Nerves is a public Anthem Blue Cross and Blue Shield Virginia policy (policy SURG.00155). It lists 8 CPT or HCPCS codes, 7 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
- SURG.00155
- 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 |
|---|---|---|---|
| 0440T | On the list | Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve | Policies naming 0440T |
| 0441T | On the list | Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve | Policies naming 0441T |
| 0442T | On the list | Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve) | Policies naming 0442T |
| 64624 | On the list | Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed | Policies naming 64624 |
| 64640 | On the list | Destruction, Neurolytic; Other Peripheral Nerve/Branch | Policies naming 64640 |
| 64999 | Not listed | Policies naming 64999 | |
| C9808 | On the list | Nerve cryoablation probe (e.g., cryoice, cryosphere, cryosphere max, cryoice cryosphere, cryoice cryo2), including probe and all disposable system components, non-opioid medic | Policies naming C9808 |
| C9809 | On the list | Cryoneurolysis needle (e.g., iovera system), including needle/tip and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid med | Policies naming C9809 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list