Anthem Blue Cross and Blue Shield Virginia prior authorization, page 2
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
| Code | Description | Source |
|---|---|---|
| 0087U | Cardiology (heart transplant), mRNA gene expression profiling by microarray of 1283 genes, transplant biopsy tissue, allograft rejection and injury algorithm reported as a pro | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0088U | Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizing transplant biopsy tissue, algorithm reported as a probabil | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0089U | Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collection using adhesive patch(es) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0090U | Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 23 genes (14 content and 9 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0094U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0095T | Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0098T | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for p | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0100T | Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0101T | Extracorporeal shock wave involving musculoskeletal system, not otherwise specified | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0101U | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel utilizing a | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0102T | Extracorporeal shock wave performed by a physician, requiring anesthesia other than local, and involving the lateral humeral epicondyle | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0102U | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0103U | Hereditary ovarian cancer (eg, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and arr | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0105U | Nephrology (chronic kidney disease), multiplex electrochemiluminescent immunoassay (ECLIA) of tumor necrosis factor receptor 1A, receptor superfamily 2 (TNFR1, TNFR2), and kid | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0106T | QST TST-EXT; TOUCH PRESS LG DIAM SENSATION | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0107T | QST TST-EXT; VIBRATION LG DIAM FIBER SENSATION | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0108T | QST-EXT; COOL SM NRV FIBR SENSATION&HYPERALGESIA | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0108U | Gastroenterology (Barrett's esophagus), whole slide-digital imaging, including morphometric analysis, computer-assisted quantitative immunolableing of 9 protein biomarkers (p1 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0109T | QST-EXT;HEAT-PAIN SM NRV FIBR SENSATN&HYPRALGSIA | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0110T | QST TST-EXT; OTHER STIMULI ASSESS SENSATION | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0111U | Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis utilizing formalin-fixed paraffin-embedded tissue | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0112U | Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug-resistance gene | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0113U | Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence-based detection, algorith | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0117U | Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxy | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0118U | Transplantation medicine, quantification of donor-derived cell-free DNA using whole genome next-generation sequencing, plasma, reported as percentage of donor-derived cell-fre | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0120U | Oncology (B-cell lymphoma classification), mRNA, gene expression profiling by fluorescent probe hybridization of 58 genes (45 content and 13 housekeeping genes), formalin-fixe | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0129U | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and deletion/dup | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0130U | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0134U | Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0136U | ATM (ataxia telangiectasia mutated) (eg, ataxia telangiectasia) mRNA sequence analysis (List separately in addition to code for primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0138U | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) mRNA sequence analysis (List separately in addition to co | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0152U | Infectious disease (bacteria, fungi, parasites, and DNA viruses), microbial cell-free DNA, plasma, untargeted next-generation sequencing, report for significant positive patho | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0153U | Oncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a tripl | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0154U | Oncology (urothelial cancer), RNA, analysis by real-time RT-PCR of the FGFR3 (fibroblast growth factor receptor 3) gene analysis (ie, p.R248C [c.742C>T], p.S249C [c.746C>G], p | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0155U | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha) (eg, breast cancer) gene analysis (ie, p.C420R, p.E542K, p.E545 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0156U | Copy number (eg, intellectual disability, dysmorphology), sequence analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0164U | Gastroenterology (irritable bowel syndrome [IBS]), immunoassay for anti-CdtB and anti- vinculin antibodies, utilizing plasma, algorithm for elevated or not elevated qualitative | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0166U | Liver disease, 10 biochemical assays (+2-macroglobulin, haptoglobin, apolipoprotein A1, bilirubin, GGT, ALT, AST, triglycerides, cholesterol, fasting glucose) and biometric a | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0169U | NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) (eg, drug metabolism) gene analysis, common variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0170U | Neurology (autism spectrum disorder [ASD]), RNA, next-generation sequencing, saliva, algorithmic analysis, and results reported as predictive probability of ASD diagnosis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0171U | Targeted genomic sequence analysis panel, acute myeloid leukemia, myelodysplastic syndrome, and myeloproliferative neoplasms, DNA analysis, 23 genes, interrogation for sequenc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0172U | Oncology (solid tumor as indicated by the label), somatic mutation analysis of BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) and analysis of homol | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0173U | Psychiatry (ie, depression, anxiety), genomic analysis panel, includes variant analysis of 14 gene | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0175U | Psychiatry (eg, depression, anxiety), genomic analysis panel, variant analysis of 15 genes | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0177U | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha) gene analysis of 11 gene variants utilizing plasma, reported as | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0179U | Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior kno | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 01937 | Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; cervical or thoracic | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 01938 | Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 01939 | Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; cervical or thoracic | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 01940 | Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |