Anthem Blue Cross and Blue Shield Virginia prior authorization, page 20

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
71270	Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further sections	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
71271	Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
71275	Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if perfo	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
71550	Mri, Chest; W/O Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
71551	Mri, Chest; W/Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
71552	Mri, Chest; W/O Contrast Matl(S), Followed By Contrast Matl(S) & Further Sequences	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
71555	Mra, Chest (Exclude Myocardium), W/Wo Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72125	Ct Scan, Cervical Spine; W/O Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72126	Ct Scan, Cervical Spine; W/Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72127	Ct Scan, Cervical Spine; W/O Contrast, Then W/Contrast & Further Sections	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72128	Computed tomography, thoracic spine; without contrast material	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72129	Cat,Thoracic Spine;w/Contrst Materl,18-2	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72130	Ct Scan, Thoracic Spine; W/O Contrast, Then W/Contrast & Further Sections	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72131	Ct Scan, Lumbar Spine; W/O Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72132	Ct Scan, Lumbar Spine; W/Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72133	Ct Scan, Lumbar Spine; W/O Contrast, Then W/Contrast & Further Sections	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72141	Mri, Cervical Spine; W/O Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72142	Mri, Cervical Spine; W/Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72146	Mri, Thoracic Spine; W/O Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72147	Mri, Thoracic Spine; W/Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72148	Mri, Lumbar Spine; W/O Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72149	Mri, Lumbar Spine; W/Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72156	Mri, Spine W/O Contrast, Then W/Contrast; Cervical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72157	Mri, Spine W/O Contrast, Then W/Contrast; Thoracic	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72158	Mri, Spine W/O Contrast, Then W/Contrast; Lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72159	Mra, Spine W/Wo Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72191	Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and ima	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72192	Ct Scan, Pelvis; W/O Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72193	Ct Scan, Pelvis; W/Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72194	Ct Scan, Pelvis; W/O Contrast, Then W/Contrast & Further Sections	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72195	Mri, Pelvis; W/O Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72196	Mri, Pelvis; W/Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72197	Mri, Pelvis; W/O Contrast Matl(S), Followed By Contrast Matl(S) & Further Sequences	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72198	Mra, Pelvis, W/Wo Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72285	Discography, cervical or thoracic, radiological supervision and interpretation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
72295	Discography, lumbar, radiological supervision and interpretation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73200	Ct Scan, Upper Extremity; W/O Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73201	Ct Scan, Upper Extremity; W/Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73202	Ct Scan, Upper Extremity; W/O Contrast, Then W/Contrast & Further Sections	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73206	Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73218	Mri, Upper Extremity, Other Than Joint; W/O Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73219	Mri, Upper Extremity, Other Than Joint; W/Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73220	Mri, Upper Extremity, Other Than Joint; W/O Contrast Matl(S), Followed By Contrast Matl(S) & Sequenc	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73221	Mri, Any Joint, Upper Extremity; W/O Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73222	Mri, Any Joint, Upper Extremity; W/Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73223	Mri, Any Joint Of Upper Extremity; W/O Contrast Matl(S), Followed By Contrast Matl(S) & Further Sequ	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73225	Mra, Upper Extremity, W/Wo Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73700	Ct Scan, Lower Extremity; W/O Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73701	Ct Scan, Lower Extremity; W/Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73702	Ct Scan, Lower Extremity; W/O Contrast, Then W/Contrast & Further Sections	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.