Anthem Blue Cross and Blue Shield Virginia prior authorization, page 12

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
43336	Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 20 Original policy
43337	Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; with implantation of mesh or other prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 20 Original policy
43631	Gastrectomy, Partial, Distal; W/Gastroduodenostomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 20 Original policy
43632	Gastrectomy, Partial, Distal; W/Gastrojejunostomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 20 Original policy
43633	Gastrectomy, Partial, Distal; W/Roux-En-Y Reconstruction	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43644	Laparoscopy, Surg, Gastric Restrictive Procedure; W Gastric Bypass And Roux-En-Y Gastroenterostomy (Roux Limb <= 150 Cm)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43645	Laparoscopy, Surgical, Gastric Restrictive Procedure; With Gastric Bypass And Small Intestine Reconstruction	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43770	Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric ba	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43771	Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43772	Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43773	Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device c	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43774	Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43775	Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43842	Gastric Restrictive Proc, W/O Gastric Bypass, Morbid Obesity; Vertical-Banded Gastroplasty	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43843	Gastric Restrictve Proc, W/O Gastric Bypass, Morbid Obesity; Non-Vertical-Banded Gastroplasty	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43845	Gastric Stapling Morbid Obesity	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43846	Gastric Restrictve Procedre, W/Gastric Bypass, Morbd Obsty; W/Short Limb Roux-En-Y Gastroenterostmy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43847	Gastric Restrictive Proc, W/Gastric Bypass, Morbid Obesity; W/Small Bowel Reconstruction	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43848	Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (s	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43886	Gastric restrictive procedure, open; revision of subcutaneous port component only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43887	Gastric restrictive procedure, open; removal of subcutaneous port component only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43888	Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
43999	Unlisted Proc, Stomach	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
44132	Donor Enterectomy, Open, W/Prep & Maintenance, Allograft; Cadaver Donor	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
44133	Donor Enterectomy, Open With Prep & Maintenance, Allograft; Partial, Living Donor	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
44135	Intestinal Allotransplantation; From Cadaver Donor	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
44136	Intestinal Allotransplantation; From Living Donor	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
44715	Backbench Standard Preparation Of Cadaver Or Living Donor Intestine Allograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
44720	Backbench Reconstruction Of Cadaver Or Living Donor Intestine Allograft; Venous Anastomosis, Each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
44721	Backbench Reconstruction Of Cadaver Or Living Donor Intestine Allograft; Arterial Anastomosis, Each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
45560	Repair, Rectocele (Sep Proc)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
46707	Repair of anorectal fistula with plug (eg, porcine small intestine submucosa [SIS])	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
46948	Hemorrhoidectomy, internal, by transanal hemorrhoidal dearterialization, 2 or more hemorrhoid columns/groups, including ultrasound guidance, with mucopexy, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47120	Hepatectomy, Resection, Liver; Partial Lobectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47122	Hepatectomy, Resection, Liver; Trisegmentectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47125	Hepatectomy, Resection, Liver; Total Left Lobectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47130	Hepatectomy, Resection, Liver; Total Right Lobectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47133	Donor Hepatectomy, W/Preparation & Maintenance, Allograft; Cadaver Donor	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47135	Liver Allotransplantation; Orthotopic, Partial/Whole, Cadaver/Living Donor, Any Age	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47140	Donor Hepatectomy, with Preparation and Maintenance of Allograft, Living Donor; Left Lateral Segment Only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47141	Donor Hepatectomy, with Preparation and Maintenance of Allograft, Living Donor; Total Left Lobectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47142	Donor Hepatectomy, with Preparation and Maintenance of Allograft, Living Donor; Total Right Lobectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47143	Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft; Without Trisegment Or Lobe Split	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47144	Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectom	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47145	Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectom	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47146	Backbench Reconstruction Of Cadaver Or Living Donor Liver Graft Prior To Allotransplantation; Venous Anastomosis, Each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47147	Backbench Reconstruction Of Cadaver Or Living Donor Liver Graft Prior To Allotransplantation; Arterial Anastomosis, Each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47370	Laparoscopy, Surgical, Ablation 1+ Liver Tumor(S); Radiofrequency	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47371	Laparoscopy, Surgical, Ablation 1+ Liver Tumor(S); Cryosurgical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47380	Ablation, Open, 1+ Liver Tumor(S); Radiofrequency	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy

Sources

Disclaimer

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.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.