Anthem Blue Cross and Blue Shield Virginia prior authorization, page 11

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

Prior authorization codes
Code	Description	Source
23410	Repair, Ruptured Musculotendinous Cuff, Open; Acute	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23412	Repair, Ruptured Musculotendinous Cuff; Chronic	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23415	Coracoacromial Ligament Release, W/Wo Acromioplasty	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23420	Reconstruction, Complete Shoulder (Rotator) Cuff Avulsion, Chronic (Includes Acromioplasty)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23430	Tenodesis, Long Tendon, Biceps	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23440	Resection/Transplantation, Long Tendon, Biceps	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23450	Capsulorrhaphy, Anterior; Putti-Platt Proc/Magnuson Type Operation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23455	Capsulorrhaphy, Anterior; W/Labral Repair	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23460	Capsulorrhaphy, Anterior, Any Type; W/Bone Block	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23462	Capsulorrhaphy, Anterior, Any Type; W/Coracoid Process Transfer	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23465	Capsulorrhaphy, Glenohumeral Joint, Posterior, W/Wo Bone Block	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23466	Capsulorrhaphy, Glenohumeral Joint, Any Type Multi-Directional Instability	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23470	Arthroplasty, Glenohumeral Joint; Hemiarthroplasty	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23472	Arthroplasty, Glenohumeral Joint; Total Shoulder	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23473	Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23474	Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
23700	Manipulation W/Anesthesia, Shoulder Joint, W/Application Of Fixation Apparatus (Excl Dislocation)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
24300	Manipulation, Elbow, Under Anesthesia	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
25259	Manipulation, Wrist, Under Anesthesia	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
26340	Manipulation, Finger Joint, Under Anesthesia, Each Joint	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27096	Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27120	Acetabuloplasty	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27122	Acetabuloplasty; Resection, Femoral Head	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27125	Hemiarthroplasty, Hip, Partial	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27130	Arthroplasty, Acetabular/Proximal Femoral Prosthetic Replacement, W/Wo Autograft/Allograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27132	Conversion, Previous Hip Surgery To Total Hip Arthroplasty, W/Wo Autograft/Allograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27134	Revision, Total Hip Arthroplasty; Both Components, W/Wo Autograft/Allograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27137	Revision, Total Hip Arthroplasty; Acetabular Component Only, W/Wo Autograft/Allograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27138	Revision, Total Hip Arthroplasty; Femoral Component Only, W/Wo Allograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27275	Manipulation, Hip Joint, Requiring General Anesthesia	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27279	Arthrodesis, sacroiliac joint, percutaneous or minimally invasive, with image guidance, includes obtaining bone graft when performed, unilateral; placement of transarticular d	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27280	Arthrodesis, sacroiliac joint, open, includes obtaining bone graft, including instrumentation, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27331	Arthrotomy, Knee; W/Joint Exploration, Bx/Removal, Loose/Fb	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27332	Arthrotomy, W/Excision, Semilunar Cartilage (Meniscectomy) Knee; Medial/Lateral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27333	Arthrotomy, W/Excision, Semilunar Cartilage (Meniscectomy) Knee; Medial & Lateral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27334	Arthrotomy, W/Synovectomy Knee; Anterior/Posterior	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27335	Arthrotomy, W/Synovectomy Knee; Anterior & Posterior W/Popliteal Area	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27345	Excision, Synovial Cyst, Popliteal Space	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27403	Arthrotomy W/Meniscus Repair, Knee	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27405	Repair, Primary, Torn Ligament &/Or Capsule, Knee; Collateral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27407	Repair, Primary, Torn Ligament &/Or Capsule, Knee; Cruciate	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
27409	Repair, Primary, Torn Ligament &/Or Capsule, Knee; Collateral & Cruciate Ligaments	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 15 Original policy
43284	Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band), including cruroplasty when performed.	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 20 Original policy
43285	Removal of esophageal sphincter augmentation device	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 20 Original policy
43290	Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 20 Original policy
43291	Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 20 Original policy
43332	Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 20 Original policy
43333	Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 20 Original policy
43334	Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or other prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 20 Original policy
43335	Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; with implantation of mesh or other prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 20 Original policy

Sources

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The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

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