Anthem Blue Cross and Blue Shield Virginia prior authorization, page 46

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
87536	Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification, includes reverse transcription when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87537	Infectious Agent, Nucleic Acid (Dna/Rna); Hiv-2, Direct Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87538	Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique, includes reverse transcription when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87539	Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification, includes reverse transcription when performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87540	Infectious Agent, Nucleic Acid (Dna/Rna); Legionella Pneumophila, Direct Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87541	Infectious Agent, Nucleic Acid (Dna/Rna); Legionella Pneumophila, Amplified Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87542	Infectious Agent, Nucleic Acid (Dna/Rna); Legionella Pneumophila, Quantification	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87550	Infectious Agent, Nucleic Acid (Dna/Rna); Mycobacteria Species, Direct Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87551	Infectious Agent, Nucleic Acid (Dna/Rna); Mycobacteria Species, Amplified Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87552	Infectious Agent, Nucleic Acid (Dna/Rna); Mycobacteria Species, Quantification	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87555	Infectious Agent, Nucleic Acid (Dna/Rna); Mycobacteria Tb, Direct Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87556	Infectious Agent, Nucleic Acid (Dna/Rna); Mycobacteria Tb, Amplified Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87557	Infectious Agent, Nucleic Acid (Dna/Rna); Mycobacteria Tb, Quantification	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87560	Infectious Agent, Nucleic Acid (Dna/Rna); Mycobacteria Avium-Intracellulare, Direct Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87561	Infectious Agent, Nucleic Acid (Dna/Rna); Mycobacteria Avium-Intracellulare, Amplified Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87562	Infectious Agent, Nucleic Acid (Dna/Rna); Mycobacteria Avium-Intracellulare, Quantification	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87563	Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87580	Infectious Agent, Nucleic Acid (Dna/Rna); Mycoplasma Pneumoniae, Direct Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87581	Infectious Agent, Nucleic Acid (Dna/Rna); Mycoplasma Pneumoniae, Amplified Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87582	Infectious Agent, Nucleic Acid (Dna/Rna); Mycoplasma Pneumoniae, Quantification	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87590	Infectious Agent, Nucleic Acid (Dna/Rna); Neisseria Gonorrhoeae, Direct Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87591	Infectious Agent, Nucleic Acid (Dna/Rna); Neisseria Gonorrhoeae, Amplified Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87592	Infectious Agent, Nucleic Acid (Dna/Rna); Neisseria Gonorrhoeae, Quantification	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87623	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low- risk types (eg, 6, 11, 42, 43, 44)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87624	Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68), pooled result	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87625	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87631	Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syn	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87632	Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syn	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87633	Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syn	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87634	Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe technique	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87635	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe techniq	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87640	Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87641	Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe t	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87650	Infectious Agent, Nucleic Acid (Dna/Rna); Streptococcus Group A, Direct Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87651	Infectious Agent, Nucleic Acid (Dna/Rna); Streptococcus Group A, Amplified Probe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87652	Infectious Agent, Nucleic Acid (Dna/Rna); Streptococcus Group A, Quantification	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87653	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87660	Infectious Agent Detection By Nucleic Acid (DNA or RNA); Trichomonas Vaginalis, Direct Probe Technique	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87661	Infectious agent detection by nucleic acid (dna or rna); trichomonas vaginalis, amplified probe technique	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87662	Infectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe technique	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87797	Infectious Agent, Nucleic Acid (Dna/Rna), Nos; Direct Probe Technique, Ea Organism	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87798	Infectious Agent, Nucleic Acid (Dna/Rna), Nos; Amplified Probe Technique, Ea Organism	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 53 Original policy
87799	Infectious Agent, Nucleic Acid (Dna/Rna), Nos; Quantification, Ea Organism	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 54 Original policy
87800	Infectious Agent, Nucleic Acid (Dna/Rna), Multiple Organisms; Direct Probe(S) Technique	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 54 Original policy
87801	Infectious Agent, Nucleic Acid (Dna/Rna), Multiple Organisms; Amplified Probe(S) Technique	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 54 Original policy
87802	Infectious agent antigen detection by immunoassay with direct optical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 54 Original policy
87803	Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Clostridium difficile toxin A	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 54 Original policy
87804	Infectious agent antigen detection by immunoassay with direct optical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 54 Original policy
87806	Infectious agent antigen detection by immunoassay with direct optical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 54 Original policy
87807	Infectious agent antigen detection by immunoassay with direct optical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 54 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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