Anthem Blue Cross and Blue Shield Virginia prior authorization, page 21

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
73706	Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73718	Mri, Lower Extremity Other Than Joint; W/O Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 28 Original policy
73719	Mri, Lower Extremity Other Than Joint; W/Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
73720	Mri, Lower Extremity, Other Than Joint; W/O Contrast Matl(S), Followed Contrast Matl(S) & Furthr Seq	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
73721	Mri, Any Joint, Lower Extremity; W/O Contrast Matl	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
73722	Mri, Any Joint, Lower Extremity; W/Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
73723	Mri, Any Joint, Lower Extremity; W/O Contrast Matl(S), Followed By Contrast Matl(S) & Further Seq	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
73725	Mra, Lower Extremity, W/Wo Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74150	Ct Scan, Abdomen; W/O Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74160	Computed tomography, abdomen; with contrast material(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74170	Ct Scan, Abdomen; W/O Contrast, Then W/Contrast & Further Sections	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74174	Computed Tomographic Angiography, Abdomen And Pelvis, With Contrast Material(S), Including Noncontrast Images, If Performed, And Image Postprocessing	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74175	Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and im	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74176	Computed tomography, abdomen and pelvis; without contrast material	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74177	Computed tomography, abdomen and pelvis; with contrast material(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74178	Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regio	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74181	Mri, Abdomen; W/O Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74182	Mri, Abdomen; W/Contrast Matl(S)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74183	Mri, Abdomen; W/O Contrast Matl(S) Followed By Contrast Matl(S) & Further Sequences	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74185	Mra, Abdomen, W/Wo Contrast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74261	Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74262	Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74263	Computed tomographic (CT) colonography, screening, including image postprocessing	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
74712	Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single of first gestation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
75557	Cardiac magnetic resonance imaging for morphology and function without contrast material	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
75559	Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
75561	Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast materi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
75563	Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast materi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
75571	Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
75572	Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D ima	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
75573	Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postproce	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
75574	Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, inc	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
75580	Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of the data set from a coronary computed tomography angiography, wit	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
75635	Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast materi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
76120	Cineradiography/Videoradiology, Except Where Specifically Included	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
76376	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under co	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
76377	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under co	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
76390	Mr Spectroscopy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
76391	Magnetic resonance (eg, vibration) elastography	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
76873	Echography, Transrectal; Prostate Volume Study, Brachytherapy Planning	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
76965	Us Guided, Interstitial Radioelement Application	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77046	Magnetic resonance imaging, breast, without contrast material; unilateral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77047	Magnetic resonance imaging, breast, without contrast material; bilateral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77048	Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokin	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77049	Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokin	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77078	Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77084	Magnetic resonance (eg, proton) imaging, bone marrow blood supply	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77295	3-dimensional radiotherapy plan, including dose-volume histograms	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77301	Intensity Modulated Radiotherapy Plan W/Dose Volume Histograms	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77316	Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy

Sources

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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.

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