Anthem Blue Cross and Blue Shield Virginia prior authorization, page 23

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
78608	Brain Imaging, Positron Emission Tomography (Pet); Metabolic Evaluation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78609	Brain Imaging, Positron Emission Tomography (Pet); Perfusion Evaluation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78811	Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78812	Positron emission tomography (PET) imaging; skull base to mid-thigh	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78813	Positron emission tomography (PET) imaging; whole body	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78814	Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and an	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78815	Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and an	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
78816	Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and an	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
79101	Radiopharmaceutical Therapy, By Intravenous Administration	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
79403	Radiopharmaceutical Therapy, Radiolabeled Monoclonal Antibody By Intravenous Infusion	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
80047	Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (8256	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
80048	Basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) G	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
80050	General Health Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
80051	Electrolyte Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 30 Original policy
80053	Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, t	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80055	Obstetric panel This panel must include the following: Blood count, complete (CBC), automated and automated differential	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80061	Lipid Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80069	Renal function panel This panel must include the following: Albumin (82040) Calcium, total (82310) Carbon dioxide (bicar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80074	Acute Hepatitis Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80076	Hepatic Function Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80150	Assay Of Amikacin	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80155	Caffeine	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80156	Assay Of Carbamazepine; Total	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80157	Assay Of Carbamazepine; Free	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80158	Assay Of Cyclosporine	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80159	Clozapine	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80162	Assay Of Digoxin	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80163	Digoxin; free	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80164	Assay Of Dipropylacetic Acid (Valproic Acid)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80165	Valproic acid (dipropylacetic acid); free	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80168	Assay Of Ethosuximide	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80169	Everolimus	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80170	Assay Of Gentamicin	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80171	Gabapentin	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80173	Assay Of Haloperidol	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80175	Lamotrigine	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80176	Assay Of Lidocaine	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80177	Levetiracetam	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80178	Assay Of Lithium	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80180	Mycophenolate (mycophenolic acid)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80183	Oxcarbazepine	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80184	Assay Of Phenobarbital	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80185	Assay Of Phenytoin; Total	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80186	Assay Of Phenytoin; Free	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80187	Posaconazole	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80188	Assay Of Primidone	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80190	Assay Of Procainamide	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80192	Assay Of Procainamide; W/Metabolites	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80194	Assay Of Quinidine	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80195	Sirolimus	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 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.