Anthem Blue Cross and Blue Shield Virginia prior authorization, page 15

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
58291	Vaginal Hysterectomy, Uterus >250 Gms; W/Removal, Tube(S) &/Or Ovary(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58292	Vaginal Hysterectomy, Uterus >250 Gms; W/Removal, Tube(S) &/Or Ovary(S) W/Repair Of Enterocele	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58294	Vaginal Hysterectomy, Uterus >250 Gms; W/Repair Of Enterocele	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58541	Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58542	Laparoscopy, surgical, supracervical 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
58543	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58544	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58545	Laparoscopy, Surg, Myomectomy; 1-4 Intramural Myomas, Total Wt 250 Gms, &/Or Remove Surface Myomas	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58546	Laparoscopy, Surg, Myomectomy; 5/> Intramural Myomas &/Or Total Wt >250 Gms	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58548	Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58550	Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus 250gms/<	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58552	Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus 250gms/<; W/Removal, Tube(S) &/Or Ovary(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58553	Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus >250gms	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58554	Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus >250gms; W/Remove Tube(S) &/Or Ovary(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58570	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58571	Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less;with removal of tube(s) and/or ovary (s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58572	Laparoscopy; surgical, with total hysterectomy, for uterus greater than 250 g	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58573	Laparoscopy; surgical, with total hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary (s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58580	Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58674	Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency.	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58953	Bilat Salpingo-Oophorect W/Omentect, Total Abdom Hyster & Radical Dissect Debulk	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58954	Bilat Salping-Oophorec W/Omentec, Tl Abd Hyst & Radcl Dissec, Debul; W/Pelv & Ltd Paraaortic Lymp	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 23 Original policy
58956	Bilateral Salpingo-Oophorectomy With Total Omentectomy, Total Abdominal Hysterectomy For Malignancy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
59840	Induced abortion, dilation and curettage	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
59841	Induced abortion, dilation and evacuation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
59866	Multifetal Pregnancy Reduction(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
60660	Percutaneous ablation of 1 or more thyroid nodule(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61215	Insertion, Subq Reservoir/Pump/Infusion System, Ventricular Catheter	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61630	Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61635	Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angiop	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61715	MRI guided focused ultrasound high intensity stereotactic intracranial ablation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61736	Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 si	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61737	Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; multiple trajectories for	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61790	Creation, Lesion, Stereotactic, Percutaneous, Neurolytic Agent; Gasserian Ganglion	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61791	Creation, Lesion, Stereotactic, Percutaneous, Neurolytic Agent; Trigeminal Medullary Tract	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61796	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61798	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61850	Twist Drill/Burr Hole(S), Implantation, Neurostimulator Electrodes, Cortical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61860	Craniectomy/Craniotomy, Implantation, Neurostimulator Electrodes, Cerebral, Cortical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61863	Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, wo Intraop Microelectrode Recording; First Array	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61867	Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, w Intraop Microelectrode Recording; First Array	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61885	Subq Placement Cranial Neurostimulator Pulse Generator/Receiver; W/Connection Sngle Electrod Array	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61886	Subq Placement Cranial Neurostimulator Pulse Generator/Receiver; W/Connection 2+ Electrode Arrays	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61889	Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, when performed, with direct or inductive coupling, with co	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
61891	Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode array(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
62263	Lysis, Perq, Epidural Adhesions, Solution Injection/Mechanical W/Radiologic Localization; 2 Days/>	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
62264	Lysis, Perq Epidural Adhesions, Solution Injection/Mechanical W/Radiologic Localization; 1 Day	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
62281	Injection/Infusion Neurolytic Substance, W/Wo Therapeutic Substance; Epidural Cervical/Thoracic	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
62282	Injection/Infusion Neurolytic Substance; Epidural, Lumbar/Caudal	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
62287	Decompression, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle-based technique to remove disc material under fluoroscopic imaging or othe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 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.