Anthem Blue Cross and Blue Shield Virginia prior authorization, page 50

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
89290	Biopsy, Oocyte Polar Body or Embryo Blastomere, Microtechnique; Less Than or Equal To 5 Embryos	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 56 Original policy
89291	Biopsy, Oocyte Polar Body or Embryo Blastomere, Microtechnique; Greater Than 5 Embryos	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 56 Original policy
89329	Sperm Evaluation; Hamster Penetration Test	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 56 Original policy
89330	Sperm Evaluation; Cervical Mucus Penetration Test, W/Wo Spinnbarkeit Test	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 56 Original policy
89337	Cryopreservation, mature oocyte(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 56 Original policy
89344	Storage, (Per Year); Reproductive Tissue, Testicular/Ovarian	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 56 Original policy
89346	Storage, (Per Year); Oocyte	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 56 Original policy
89354	Thawing of Cryopreserved; Reproductive Tissue, Testicular/Ovarian	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 56 Original policy
89356	Thawing of Cryopreserved; Oocytes, Each Aliquot	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 56 Original policy
90281	Immune Globulin (Ig), Human, Im Use	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 56 Original policy
90283	Immune Globulin (Igiv), Human, Iv Use	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
90284	Immune globulin (SCIg), human, for use in subcutaneous infusions, 100mg, each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
90378	Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
90380	Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
90381	Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
90867	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
90868	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
90869	Therapeutic Repetitive Transcranial Magnetic Stimulation (Tms) Treatment; Subsequent Motor Threshold Re-Determination With Delivery And Management	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
90875	Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior m	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
90876	Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior m	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
90901	Biofeedback Training, Any Modality	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
90912	Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qu	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
90913	Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
91112	Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92521	Evaluation of speech fluency (eg, stuttering, cluttering)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92522	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92523	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive an	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92524	Behavioral and qualitative analysis of voice and resonance	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92526	Treatment, Swallowing Dysfunction &/Or Oral Function, Feeding	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92605	Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92606	Therapeutic Service(S), Use Non-Speech Generatiing Device, W/Programming & Modification	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92607	Eval, Prescription, Speech-Generating Augmentative & Alternative Communication Device; 1st Hr	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92608	Eval, Prescrip, Speech-Generating Augmentative & Alternative Communication Device; Ea Add'l 30 Min	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92609	Therapeutic Services, Non-Speech Generative Device Use, W/Programming & Modification	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92610	Eval, Oral & Pharyngeal Swallow Function	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92611	Motion Fluoroscopic Eval, Swallow Function, Cine/Video Record	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92618	Evaluation For Prescription Of Non-Speech-Generating Augmentative And Alternative Communication Device, Face-To-Face With The Patient; Each Additional 30 Minutes (List Separat	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92626	Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); first hour	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92627	Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); each additional 15 minutes (List sepa	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92630	Auditory rehabilitation; pre-lingual hearing loss	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92633	Auditory rehabilitation; post-lingual hearing loss	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92920	Percutaneous transluminal coronary angioplasty, single major coronary artery and/or its branch(es)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92924	Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed, single major coronary artery and/or its branch(es)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92928	Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed, single major coronary artery and/or its branch(es); 1 lesion involvin	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92930	Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed, single major coronary artery and/or its branch(es); 2 or more distinct coronary lesions with 2 or more coronary stents deployed in 2 or more coronary segments, or	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92933	Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed, single major coronary artery and/or its branch(es)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92937	Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, ather	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92943	Percutaneous transluminal revascularization of chronic total occlusion, single coronary artery, coronary artery branch, or coronary artery bypass graft, and/or subtended major	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 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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