Anthem Blue Cross and Blue Shield Virginia prior authorization, page 13

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
47381	Ablation, Open, 1+ Liver Tumor(S); Cryosurgical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47382	Ablation, Open, 1+ Liver Tumor(S), Percutaneous, Radiofrequency	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
47383	Ablation, 1 or more liver tumor(s), percutaneous, cryoablation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
48160	Pancreatectomy, Total/Subtotal W/Autologous Transplantation Pancreas/Pancreatic Islets	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
48550	Donor Pancreatectomy, W/Prep & Maintenance, Cadaver Donor, W/Wo Duodenal Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
48551	Backbench Standard Preparation Of Cadaver Donor Pancreas Allograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
48552	Backbench Reconstruction Of Cadaver Donor Pancreas Allograft Prior To Transplantation, Venous Anastomosis, Each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
48554	Transplantation, Pancreatic Allograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
48556	Removal, Transplanted Pancreatic Allograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
50250	Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 21 Original policy
50300	Donor Nephrectomy; Cadaver Donor, Unilat/Bilat W/Prep & Maintenance, Allograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
50320	Donor Nephrectomy, Open, Living Donor W/O Allograft Preparation & Maintenance	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
50323	Backbench Standard Preparation Of Cadaver Donor Renal Allograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
50325	Backbench Standard Preparation Of Living Donor Renal Allograft (Open Or Laparoscopic)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
50327	Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Venous Anastomosis, Each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
50328	Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Arterial Anastomosis, Each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
50329	Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Ureteral Anastomosis, Each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
50340	Recipient Nephrectomy (Sep Proc)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
50360	Renal Allotransplantation, Implantation, Graft; W/O Donor & Recipient Nephrectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
50365	Renal Allotransplantation, Implantation, Graft; W/Recipient Nephrectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
50542	Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
50547	Laparoscopy, Surgical; Donor Nephrectomy, Living Donor W/O Allograft Prep & Maintenance	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
50592	Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
50593	Ablation, renal tumor(s), unilateral, presutaneous cryotherapy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
51715	Endoscopic Injection, Implant Matl Into Submucosal Tissues, Urethra &/Or Bladder Neck	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
51721	Transurethral ablation transducer insertion for delivery of thermal ultrasound for prostate	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
52441	Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
52450	Transurethral Incision, Prostate	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
52648	Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
52649	Laser enucleation of the prostate with morcellation including control of postoperative bleeding, complete (vasectomy, me	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53445	Insertion, Inflatable Urethra/Bladder Neck Sphincter, W/Placement Pump &/Or Reservoir & Cuff	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53446	Removal, Inflatable Urethral/Bladder Neck Sphincter W/Pump/Reservoir/Cuff	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53447	Removal & Replacement, Inflatable Sphincter W/Pump, Reservoir, Cuff, Same Session	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53448	Remov & Replace Inflatable Sphincter W/Pump/Reservoir/Cuff, Infected, W/Irrig & Debride	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53449	Repair, Inflatable Urethral/Bladder Neck Sphincter Device, Incl Pump/Reservoir/Cuff	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53451	Periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53452	Periurethral transperineal adjustable balloon continence device; unilateral insertion, including cystourethroscopy and imaging guidance	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53453	Periurethral transperineal adjustable balloon continence device; removal, each balloon	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53454	Periurethral transperineal adjustable balloon continence device; percutaneous adjustment of balloon(s) fluid volume	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53850	Transurethral Destruction, Prostate Tissue; Microwave Thermotherapy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53852	Transurethral Destruction, Prostate Tissue; Radiofrequency Thermotherapy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53854	Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53855	Insertion of a temporary prostatic urethral stent, including urethral measurement	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
53860	Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
54125	Amputation, Penis; Complete	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
54360	Plastic Operation, Penis To Correct Angulation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
54400	Insertion, Penile Prosthesis; Non-Inflatable (Semi-Rigid)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
54401	Insertion, Penile Prosthesis; Inflatable (Self-Contained)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
54405	Insertion, (Multi-Component) Inflatable Penile Prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
54410	Removal & Replacement, Multi-Component Inflatable Penile Prosthesis, Same Session	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 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.

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.

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