Anthem Blue Cross and Blue Shield Virginia prior authorization, page 18

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
64590	Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pu	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64596	Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode arra	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64600	Destruction, Neurolytic, Trigeminal Nerve; Supraorbital/Infraorbital/Mental/Inferior Alveolar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64605	Destruction, Neurolytic, Trigeminal Nerve; 2nd & 3rd Division	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64610	Destruction, Neurolytic, Trigeminal Nerve; 2nd & 3rd Division W/Radiologic Monitoring	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64616	Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64617	Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle electromyography, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64624	Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64625	Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64628	Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64629	Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to code	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64633	Destruction By Neurolytic Agent, Paravertebral Facet Joint Nerve(S), With Imaging Guidance (Fluoroscopy Or Ct); Cervical Or Thoracic, Single Facet Joint	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64634	Destruction By Neurolytic Agent, Paravertebral Facet Joint Nerve(S), With Imaging Guidance (Fluoroscopy Or Ct); Cervical Or Thoracic, Each Additional Facet Joint (List Separat	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64635	Destruction By Neurolytic Agent, Paravertebral Facet Joint Nerve(S), With Imaging Guidance (Fluoroscopy Or Ct); Lumbar Or Sacral, Single Facet Joint	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64636	Destruction By Neurolytic Agent, Paravertebral Facet Joint Nerve(S), With Imaging Guidance (Fluoroscopy Or Ct); Lumbar Or Sacral, Each Additional Facet Joint (List Separately	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64640	Destruction, Neurolytic; Other Peripheral Nerve/Branch	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64654	Initial open implantation of baroreflex activation therapy (BAT) modulation system, including lead placement onto the carotid sinus, lead tunnelling, connection to a pulse generator placed in a distant subcutaneous pocket (ie, total system), and intraoperative interrogation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64655	Revision or replacement of baroreflex activation therapy (BAT) modulation system, with intraoperative interrogation and programming; lead only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64656	Revision or replacement of baroreflex activation therapy (BAT) modulation system, with intraoperative interrogation and programming; pulse generator only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64657	Removal of baroreflex activation therapy (BAT) modulation system; total system, including lead and pulse generator	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64658	Removal of baroreflex activation therapy (BAT) modulation system; lead only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64659	Removal of baroreflex activation therapy (BAT) modulation system; pulse generator only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64716	Neuroplasty &/Or Transposition; Cranial Nerve (Specify)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64722	Decompression; Unspecified Nerve(S) (Specify)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64732	Transection/Avulsion; Supraorbital Nerve	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64734	Transection/Avulsion; Infraorbital Nerve	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64736	Transection/Avulsion; Mental Nerve	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64738	Transection/Avulsion; Inferior Alveolar Nerve, Osteotomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64740	Transection/Avulsion; Lingual Nerve	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64742	Transection/Avulsion; Facial Nerve, Differential/Complete	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64744	Transection/Avulsion; Greater Occipital Nerve	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64771	Transection/Avulsion, Other Cranial Nerve, Extradural	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64772	Transection/Avulsion, Other Spinal Nerve, Extradural	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64864	Suture, Facial Nerve; Extracranial	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64865	Suture, Facial Nerve; Infratemporal, W/Wo Grafting	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64866	Anastomosis; Facial-Spinal Accessory	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
64868	Anastomosis; Facial-Hypoglossal	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
65778	Placement of amniotic membrane on the ocular surface; without sutures	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
65779	Placement of amniotic membrane on the ocular surface; single layer, sutured	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
65780	Ocular surface reconstruction; amniotic membrane transplantation, multiple layers	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 26 Original policy
66174	Transluminal dilation of aqueous outflow canal (eg, canaloplasty); without retention of device or stent	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
66175	Transluminal dilation of aqueous outflow canal (eg, canaloplasty); with retention of device or stent	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
66183	Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
66683	Iris prosthesis Implantation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
66989	Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsif	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
66991	Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsif	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
67027	Implant, Intravitreal Drug Delivery System W/Removal, Vitreous	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
67218	Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; radiation by implantation of	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
67900	Repair, Brow Ptosis, (Supraciliary/Mid-Forehead/Coronal Approach)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
67901	Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy

Sources

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