Anthem Blue Cross and Blue Shield Virginia prior authorization, page 19

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
67902	Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
67903	Repair, Blepharoptosis; (Tarso) Levator Resection/Advancement, Int Approach	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
67904	Repair, Blepharoptosis; (Tarso) Levator Resection/Advancement, Ext Approach	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
67906	Repair, Blepharoptosis; Superior Rectus W/Fascial Sling	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
67908	Repair, Blepharoptosis; Conjunctivo-Tarso-Muller's Muscle-Levator Resection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69090	Ear Piercing	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69300	Otoplasty, Protruding Ear, W/Wo Size Reduction	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69399	Unlisted Proc, Ext Ear	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69705	Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); unilateral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69706	Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); bilateral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69710	Implantation/Replacement, Electromagnetic Bone Conduction Hearing Device, Temporal Bone	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69714	Implantation, osseointegrated implant, skull; with percutaneous attachment to external speech processor	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69716	Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or resulting in removal of less than	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69717	Replacement (including removal of existing device), osseointegrated implant, skull; with percutaneous attachment to external speech processor	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69719	Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid an	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69729	Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside of the mastoid and resulting in removal of greater	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69730	Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside the mastoid a	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69930	Cochlear Device Implantation, W/Wo Mastoidectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
69955	Total Facial Nerve Decompression &/Or Repair, (May Include Graft)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70336	Mri, Temporomandibular Joints	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70450	Ct Scan, Head/Brain; W/O Contrast Matl	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70460	Ct Scan, Head/Brain; W/Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70470	Ct Scan, Head/Brain; W/O Contrast, Then W/Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70480	Ct Scan, Orbit/Sella/Posterior Fossa/Outer, Middle, Inner Ear; W/O Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70481	Ct Scan, Orbit/Sella/Posterior Fossa/ Outer, Middle, Inner Ear; W/Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70482	Ct Scan, Orbit/Sella/Posterior Fossa/ Outer, Middle, Inner Ear; W/O Contrast, Then W/Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70486	Ct Scan, Maxillofacial Area; W/O Contrast Matl	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70487	Ct Scan, Maxillofacial Area; W/Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70488	Ct Scan, Maxillofacial Area; W/O Contrast, Then W/Contrast & Further Sections	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70490	Ct Scan, Soft Tissue Neck; W/O Contrast Matl	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70491	Ct Scan, Soft Tissue Neck; W/Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70492	Ct Scan, Neck Tissue; W/O Contrast, Then W/Contrast & Further Sections	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70496	Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70498	Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70540	Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70542	Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70543	Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast ma	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70544	Mra, Head; W/O Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70545	Mra, Head; W/Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70546	Mra, Head; W/O Contrast Matl(S), Followed By Contrast Matl(S) & Further Sequences	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70547	Mra, Neck; W/O Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70548	Mra, Neck; W/Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70549	Mra, Neck; W/O Contrast Matl(S), Followed By Contrast Matl(S) & Further Sequences	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70551	Mri, Brain; W/O Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70552	Mri, Brain; W/Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70553	Mri, Brain; W/O Contrast, Then W/Contrast & Further Sequences	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 27 Original policy
70554	Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part m	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
70555	Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofun	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
71250	Computed tomography, thorax, diagnostic; without contrast material	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
71260	Computed tomography, thorax, diagnostic; with contrast material(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy

Sources

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