Anthem Blue Cross and Blue Shield Virginia prior authorization, page 3
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
| Code | Description | Source |
|---|---|---|
| 01941 | Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; cervical or thoracic | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 01942 | Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; lumbar or sacral | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 01991 | Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 01992 | Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0200T | Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0201T | Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0202T | Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foramin | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0203U | Autoimmune (inflammatory bowel disease), mRNA, gene expression profiling by quantitative RT-PCR, 17 genes (15 target and 2 reference genes), whole blood, reported as a continu | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0205U | Ophthalmology (age-related macular degeneration), analysis of 3 gene variants (2 CFH gene, 1 ARMS2 gene), using PCR and MALDI-TOF, buccal swab, reported as positive or negativ | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0207T | Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 3 Original policy |
| 0209U | Cytogenomic constitutional (genome-wide) analysis, interrogation of genomic regions for copy number, structural changes and areas of homozygosity for chromosomal abnormalities | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0211U | Oncology (pan-tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded tissue, interpretative report for single nucleotide variants, copy | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0212U | Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tand | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0213T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0213U | Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tand | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0214T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0214U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tande | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0215T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0215U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tande | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0216T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0216U | Neurology (inherited ataxias), genomic DNA sequence analysis of 12 common genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0217T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0217U | Neurology (inherited ataxias), genomic DNA sequence analysis of 51 genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and va | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0218U | Neurology (muscular dystrophy), DMD gene sequence analysis, including small sequence changes, deletions, duplications, and variants in non-uniquely mappable regions, blood or | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0229U | BCAT1 (Branched chain amino acid transaminase 1) and IKZF1 (IKAROS family zinc finger 1) (eg, colorectal cancer) promoter methylation analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0230U | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation), full sequence analysis, including small sequence changes in exonic | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0231U | CACNA1A (calcium voltage-gated channel subunit alpha 1A) (eg, spinocerebellar ataxia), full gene analysis, including small sequence changes in exonic and intronic regions, del | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0232T | Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0232U | CSTB (cystatin B) (eg, progressive myoclonic epilepsy type 1A, Unverricht-Lundborg disease), full gene analysis, including small sequence changes in exonic and intronic region | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0233U | FXN (frataxin) (eg, Friedreich ataxia), gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expa | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0234U | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0235U | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0236U | SMN1 (survival of motor neuron 1, telomeric) and SMN2 (survival of motor neuron 2, centromeric) (eg, spinal muscular atrophy) full gene analysis, including small sequence chan | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0237U | Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia), genomic sequence analysis panel | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0238U | Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence changes in exonic and intronic regions, deletions, dupl | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0239U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, ins | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0242U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplif | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0244U | Oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rear | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0245U | Oncology (thyroid), mutation analysis of 10 genes and 37 RNA fusions and expression of 4 mRNA markers using next-generation sequencing, fine needle aspirate, report includes a | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0247U | Obstetrics (preterm birth), insulin-like growth factor-binding protein 4 (IBP4), sex hormone- binding globulin (SHBG), quantitative measurement by LC-MS/MS, utilizing maternal | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0248U | Oncology, spheroid cell culture in 3D microenvironment, 12-drug panel, brain- or brain metastasis-response prediction for each drug | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0250U | Oncology (solid organ neoplasm), targeted genomic sequence DNA analysi | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0253T | Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0254U | Reproductive medicine (preimplantation genetic assessment), analysis o | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0255U | Andrology (infertility), sperm-capacitation assessment of ganglioside GM1 distribution patterns, fluorescence microscopy, fresh or frozen specimen, reported as percentage of c | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0258U | Autoimmune (psoriasis), mRNA, next-generation sequencing, gene expression profiling of 50- 100 genes, skin-surface collection using adhesive patch, algorithm reported as likeli | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0260U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0262U | Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin-embedded (FFPE), algori | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0263T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete pro | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0264T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete pro | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |