Anthem Blue Cross and Blue Shield Virginia prior authorization, page 17

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
63252	Laminectomy, Excision/Occlusion, Avm, Spinal Cord; Thoracolumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63265	Laminectomy, Excision, Non-Neoplastic Lesion, Extradural; Cervical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63267	Laminectomy, Excision, Non-Neoplastic Lesion, Extradural; Lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63270	Laminectomy, Excision, Intraspinal Lesion Other Than Neoplasm, Intradural; Cervical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63272	Laminectomy, Excision, Intraspinal Lesion Other Than Neoplasm, Intradural; Lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63275	Laminectomy, Bx/Excision, Intraspinal Neoplasm; Extradural, Cervical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63277	Laminectomy, Bx/Excision, Intraspinal Neoplasm; Extradural, Lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63280	Laminectomy, Bx/Excision, Intraspinal Neoplasm; Intradural, Extramedullary, Cervical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63282	Laminectomy, Bx/Excision, Intraspinal Neoplasm; Intradural, Extramedullary, Lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63285	Laminectomy, Bx/Excision, Intraspinal Neoplasm; Intradural, Intramedullary, Cervical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63287	Laminectomy, Bx/Excision, Intraspinal Neoplasm; Intradural, Intramedullary, Thoracolumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63290	Laminectomy, Bx/Excision, Intraspinal Neoplasm; Extradural-Intradural Lesion, Any Level	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63300	Vertebral Corpectomy, 1 Segment; Extradural, Cervical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63307	Vertebral Corpectomy, 1 Segment; Intradural, Lumbar/Sacral, Transperitoneal/Retroperitoneal Approach	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63308	Vertebral Corpectomy, Add'l Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63620	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63650	Percutaneous Implantation, Neurostimulator Electrode Array, Epidural	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63655	Laminectomy, Implantation, Neurostimulator Electrodes, Plate/Paddle, Epidural	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63663	Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including flu	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63664	Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotom	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63685	Insertion or replacement of spinal neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receive	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
63688	Revision or removal of implanted spinal neurostimulator pulse generator or receiver, with detachable connection to electrode array	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
64405	Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
64415	Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
64417	Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
64447	Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
64450	Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
64454	Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
64479	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
64480	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (List separat	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
64483	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
64484	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
64490	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
64491	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 25 Original policy
64492	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64493	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64494	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64495	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64505	Injection, Anesthetic Agent; Sphenopalatine Ganglion	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64510	Injection, Anesthetic Agent; Stellate Ganglion (Cervical Sympathetic)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64520	Injection, Anesthetic Agent; Lumbar/Thoracic (Paravertebral Sympathetic)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64553	Percutaneous implantation of neurostimulator electrode array; cranial nerve	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64555	Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64561	Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64566	Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64569	Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64575	Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64581	Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64582	Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64585	Revision or removal of peripheral neurostimulator electrode array	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy

Sources

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