Anthem Blue Cross and Blue Shield Virginia prior authorization, page 10
CPT code lookup
Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| 22554 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22556 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22558 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22585 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in ad | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22586 | Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when perfor | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22590 | Arthrodesis, posterior technique, craniocervical (occiput-C2) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22595 | Arthrodesis, posterior technique, atlas-axis (C1-C2) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22600 | Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22610 | Arthrodesis, posterior or posterolateral technique, single interspace; thoracic (with lateral transverse technique, when performed) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22612 | Arthrodesis, posterior or posterolateral technique, single interspace; lumbar (with lateral transverse technique, when performed) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22614 | Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (List separately in addition to code for primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22630 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22632 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional in | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22633 | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22634 | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22800 | Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22802 | Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22804 | Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22808 | Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22810 | Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22830 | Exploration of Spinal Fusion | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22840 | Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across one interspace, atlantoax | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22841 | Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22842 | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 v | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22843 | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22844 | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or mo | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22845 | Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22846 | Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22847 | Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22848 | Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separate | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22849 | Reinsertion, Spinal Fixation Device | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22853 | Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g. screws, flanges), when performed, t | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22854 | Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g. screws, flanges), when performed, t | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22856 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompres | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22857 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); single interspace, lumbar | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22858 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompres | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22859 | Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methlmethacrylate) to intervertebral disc space or verebral body defect without interbody arthro | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22860 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (List separa | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22861 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervi | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22862 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumba | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22864 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22865 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22867 | Insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; sin | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22868 | Insertion of interlaminar/interspinous process stabilization/ distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; sec | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22869 | Insertion of interlaminar/interspinous process stabilization/ distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 22870 | Insertion of interlaminar/interspinous process stabilization/ distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 23105 | Arthrotomy; Glenohumeral Joint, W/Synovectomy, W/Wo Bx | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy |
| 23107 | Arthrotomy, Glenohumeral Joint, W/Exploration, W/Wo Loose/Fb Removal | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy |
| 23120 | Claviculectomy; Partial | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy |
| 23130 | Acromioplasty/Acromionectomy, Partial, W/Wo Coracoacromial Ligament Release | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy |