Anthem Blue Cross and Blue Shield Virginia prior authorization, page 22

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
77317	Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77318	Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77338	Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77370	Special Medical Radiation Physics Consultation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77371	Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consist	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77372	Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consist	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77373	Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, en	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77387	Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 29 Original policy
77402	Radiation treatment delivery; Level 1 (eg, single-electron field, multiple-electron fields, or 2D photons), including imaging guidance, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77407	Radiation treatment delivery; Level 2, single-isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77412	Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (eg, 2D, 3D, or IMRT) or a single-isocenter photon therapy (eg, 3D or IMRT) with active motion m	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77423	High energy neutron radiation treatment delivery, 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77424	Intraoperative Radiation Treatment Delivery, X-Ray, Single Treatment Session	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77425	Intraoperative Radiation Treatment Delivery, Electrons, Single Treatment Session	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77432	Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77435	Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image g	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77469	Intraoperative Radiation Treatment Management	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77470	Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77520	Proton Treatment Delivery; Simple W/O Compensation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77522	Proton Treatment Delivery; Simple W/Compensation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77523	Proton Treatment Delivery; Intermediate	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77525	Proton Treatment Delivery; Complex	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77761	Intracavitary Radiation Source Application; Simple	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77762	Intracavitary Radiation Source Application; Intermediate	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77763	Intracavitary Radiation Source Application; Complex	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77770	Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77771	Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77772	Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77778	Interstitial Radioelement Application; Complex	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
77790	Supervision, Handling, Loading, Radiation Source	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78429	Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single s	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78430	Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at re	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78431	Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78432	Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], w	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78433	Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], w	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78451	Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall mo	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78452	Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall mo	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78453	Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall mo	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78454	Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall mo	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78459	Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single s	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78466	Myocardial Imaging, Infarct Avid, Planar; Qualitative/Quantitative	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78468	Myocardial Imaging, Infarct Avid, Planar; W/Ejection Fraction, 1st Pass Technique	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78469	Myocardial Imaging, Infarct Avid, Planar; Tomographic Spect W/Wo Quantification	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78472	Cardiac Blood Pool Imaging, Gated Equilibrium; Planar, Single Study, Rest/Stress	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78473	Cardiac Blood Pool Imaging, Gated Equilibrium; Planar, Multiple Studies, Rest/Stress	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78481	Cardiac Blood Pool Imaging, Planar, 1st Pass; Single Study & Ejection Fraction W/Wo Quantification	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78483	Cardiac Blood Pool Imaging, Planar, 1st Pass; Mult Studies, Rest & Stress & Eject Fractn W/Wo Quant	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78491	Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at re	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78492	Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78494	Cardiac Blood Pool Imaging, Gated Equilibrium, Rest, Spect, & Ejection Fraction W/Wo Quantification	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy

Sources

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