Anthem Blue Cross and Blue Shield Virginia prior authorization, page 24

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
80197	Assay Of Tacrolimus	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80198	Assay Of Theophylline	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80199	Tiagabine	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80200	Assay Of Tobramycin	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80201	Assay Of Topiramate	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80202	Assay Of Vancomycin	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80203	Zonisamide	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80235	Lacosamide	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80285	Voriconazole	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80400	Acth Stimulation Panel; Adrenal Insufficiency	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80402	Acth Stimulation Panel; 21 Hydroxylase Deficiency	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80406	Acth Stimulation Panel; 3 Beta-Hydroxydehydrogenase Deficiency	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80408	Aldosterone Suppression Eval Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80410	Calcitonin Stimulation Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80412	Corticotropic Releasing Hormone (Crh) Stimulation Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80414	Chorionic gonadotropin stimulation panel; testosterone response This panel must include the following: Testosterone (84403 x 2 on 3 pooled blood samples)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80415	Chorionic gonadotropin stimulation panel; estradiol response This panel must include the following: Estradiol, total (82670 x 2 on 3 pooled blood samples)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80416	Renal Vein Renin Stimulation Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80417	Peripheral Vein Renin Stimulation Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80418	Combined Rapid Anterior Pituitary Eval Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 31 Original policy
80420	Dexamethasone Suppression Panel, 48 Hr	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
80422	Glucagon Tolerance Panel; Insulinoma	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
80424	Glucagon Tolerance Panel; Pheochromocytoma	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
80426	Gonadotropin Releasing Hormone Stimulation Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
80428	Growth Hormone Stimulation Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
80430	Growth Hormone Suppression Panel (Glucose Administration)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
80432	Insulin-Induced C-Peptide Suppression Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
80434	Insulin Tolerance Panel; Acth Insufficiency	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
80435	Insulin Tolerance Panel; Growth Hormone Deficiency	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
80436	Metyrapone Panel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
80438	Thyrotropin releasing hormone (TRH) stimulation panel; 1 hour This panel must include the following: Thyroid stimulating	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
80439	Thyrotropin releasing hormone (TRH) stimulation panel; 2 hour This panel must include the following: Thyroid stimulating	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81000	Urinalysis, Dip Stick/Tablet Reagent; Non-Automated W/Microscopy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81001	Urinalysis, Dip Stick/Tablet Reagent; Automated W/O Microscopy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81002	Urinalysis, Dip Stick/Tablet Reagent; Non-Automated, W/O Microscopy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81003	Urinalysis, Dip Stick/Tablet Reagent; Automated, W/O Microscopy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81005	Urinalysis; Qualitative/Semiquantitative, Except Immunoassays	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81007	Urinalysis; Bacteriuria Screen, Except By Culture/Dipstick	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81015	Urinalysis; Microscopic Only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81020	Urinalysis; 2 or 3 glass test	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81025	Urine Pregnancy Test, Visual Color Comparison Methods	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81050	Volume Measurement, Timed Collection, Each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81120	IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg, glioma), common variants (eg, R132H, R132C)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81121	IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (eg, glioma), common variants (eg, R140W, R172M)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81161	DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81162	BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplicatio	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81163	BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81164	BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, de	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81165	BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81166	BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 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.