Anthem Blue Cross and Blue Shield Virginia prior authorization, page 16

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
62290	Injection, Diskography, Each Level; Lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
62291	Injection, Diskography, Each Level; Cervical/Thoracic	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
62320	Injection(s) of diagnostic or therapeutic substance(s) (eg. anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
62321	Injection(s) of diagnostic or therapeutic substance(s) (eg. anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
62322	Injection(s) of diagnostic or therapeutic substances(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution) not including neurolytic substances, including needle	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
62323	Injection(s) of diagnostic or therapeutic substances(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution) not including neurolytic substances, including needle	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
62361	Implantation/Replace, Device, Intrathecal/Epidural Drug Infusion; Non-Programmable Pump	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
62362	Implantation/Replace, Device, Intrathecal/Epidural Drug Infusion; Programmable Pump	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
62380	Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc; 1	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63001	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral s	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63003	Laminectomy, W/O Facetectomy/Foraminotomy/Diskectomy, 1/2 Segments; Thoracic	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63005	Laminectomy W/O Facetectomy/Foraminotomy/Diskectomy, 1/2 Segments; Lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63011	Laminectomy W/O Facetectomy/Foraminotomy/Diskectomy, 1/2 Segments; Sacral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63012	Laminectomy W/Removal, Abnormal Facets, Lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63015	Laminectomy W/O Facetectomy/Foraminotomy/Diskectomy, > 2 Segments; Cervical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63017	Laminectomy W/O Facetectomy/Foraminotomy/Diskectomy, > 2 Segments; Lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63020	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63030	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63035	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additiona	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63040	Laminotomy W/Partl Facetectmy/Foramnotmy/Herniated Diskect, Re-Exploratn, Sngle Interspc; Cervical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63042	Laminotomy W/Partl Facetectomy/Foraminotomy/Herniated Diskect, Re-Explor, Sngle Interspc; Lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63043	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or ex	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63044	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or ex	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63045	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63046	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63047	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63048	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63050	Laminoplasty, Cervical, With Decompression Of The Spinal Cord, Two Or More Vertebral Segments	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 24 Original policy
63051	Laminoplasty, Cerv, W Decompression Of Spinal Cord, 2 Or > Verteb Segments; W Reconstruction Of Posterior Bony Elements	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63052	Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63053	Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63055	Transpedicular Approach, 1 Segment; Thoracic	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63056	Transpedicular Approach, 1 Segment; Lumbar (Transfacet/Lateral Extraforaminal)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63057	Transpedicular Approach, Add'l Segment; Thoracic/Lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63075	Diskectomy, Anterior; Cervical, 1 Interspace	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63076	Diskectomy, Anterior; Cervical, Add'l Interspace	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63081	Vertebral Corpectomy, Anterior; Cervical, 1 Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63082	Vertebral Corpectomy, Anterior; Cervical, Add'l Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63085	Vertebral Corpectomy, Transthoracic; Thoracic, 1 Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63086	Vertebral Corpectomy, Transthoracic; Thoracic, Add'l Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63087	Vertebral Corpectomy, Thoracolumbar, Lower Thoracic/Lumbar; 1 Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63088	Vertebral Corpectomy, Thoracolumbar, Lower Thoracic/Lumbar; Add'l Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63090	Vertebral Corpectomy, Transperitoneal/Retroperitoneal, Lower Thoracic/Lumbar/Sacral; 1 Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63091	Vertebral Corpectomy, Trans/Retroperitoneal, Lower Thoracic/Lumbar/Sacral; Add'l Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63101	Vertebral Corpectomy, Lateral Extracavitary Approach w Decompression of Spinal Cord/Nerve Roots; Thoracic, Sgl Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63102	Vertebral Corpectomy, Lateral Extracavitary Approach w Decompression of Spinal Cord/Nerve Roots; Lumbar, Sgl Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63103	Vertebral Corpectomy, Lateral Extracavitary Approach w Decompression Spinal Cord/Nerve Rts; Thoracic/Lumbar, ea addl Seg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63185	Laminectomy with rhizotomy; 1 or 2 segments	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63190	Laminectomy with rhizotomy; more than 2 segments	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63200	Laminectomy, W/Release, Tethered Spinal Cord, Lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy

Sources

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