Anthem Blue Cross and Blue Shield Virginia prior authorization, page 14

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
54411	Removal & Replacement, Multi-Component Inflatable Penile Prosthesis, Infected, W/ Irrig & Debride	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
54416	Removal & Replacement, Non-Inflatable (Semi-Rigid)/Inflatable (Self-Contained) Penile Prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
54417	Removal & Replace, Non-Inflatable/Inflatable Penile Prosthesis Infect, W/Irrig & Debride	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
54440	Plastic Operation, Penis, Injury	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
54520	Orchiectomy, Simple, W/Wo Prosthesis, Scrotal/Inguinal Approach	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
54660	Insertion, Testicular Prosthesis (Sep Proc)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
54690	Laparoscopy, Surgical; Orchiectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
55180	Scrotoplasty; Complicated	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
55860	Exposure, Prostate, Any Approach, Radiation Insertion	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
55873	Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
55874	Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
55875	Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
55880	Ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
55881	Transurethral ablation of prostate tissue, using thermal ultrasound	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
55882	Transurethral ablation of prostate tissue, using thermal ultrasound; with insertion of ultrasound transducer	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
55920	Placement of needles or catheters into pelvic organs and/or genitalia (expect prostate) for subsequent interstitial radi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 22 Original policy
56625	Vulvectomy Simple; Complete	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
56800	Plastic Repair, Introitus	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
56805	Clitoroplasty, Intersex State	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
56810	Perineoplasty, Repair, Perineum, Nonobstetrical (Sep Proc)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57110	Vaginectomy, Complete Removal, Vaginal Wall	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57155	Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57156	Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57240	Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57250	Posterior Colporrhaphy, Repair, Rectocele W/Wo Perineorrhaphy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57260	Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57268	Repair, Enterocele, Vaginal Approach (Sep Proc)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57282	Sacrospinous Ligament Fixation, Prolapse, Vagina	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57291	Construction, Artificial Vagina; W/O Graft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57292	Construction, Artificial Vagina; W/Graft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57295	Revision (including removal) of prosthetic vaginal graft, vaginal approach	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57296	Revision (including removal) of prosthetic vaginal graft; open abdominal approach	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57335	Vaginoplasty, Intersex State	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57425	Laparoscopy, Surgical, Colpopexy (Suspension of Vaginal Apex)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
57426	Revision (including removal) of prosthetic vaginal graft, laparoscopic approach	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58145	Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58150	Total Abdominal Hysterectomy W/Wo Removal Tube(S)/Ovary(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58152	Total Abdominal Hysterectomy W/Wo Removal Tube(S)/Ovary(S); W/Colpo-Urethrocystopexy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58180	Supracervical Abdominal Hysterectomy, W/Wo Removal Tube(S)/Ovary(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58200	Total Abdominal Hysterectomy, W/Partial Vaginect, W/Pelvic Node Sample, W/Wo Rem Tubes/Ovaries	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58210	Radical Abdominal Hysterectomy W/Bilat Pelvic Lymphadenectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58260	Vaginal hysterectomy, for uterus 250 g or less	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58262	Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58263	Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58267	Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall- Marchetti-Krantz type, Pereyra typ	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58270	Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58275	Vaginal Hysterectomy, W/Total/Partial Vaginectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58280	Vaginal Hysterectomy; W/Total/Partial Vaginectomy; W/Repair, Enterocele	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58285	Vaginal Hysterectomy; Radical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58290	Vaginal Hysterectomy, Uterus >250 Gms	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 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.

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