Anthem Blue Cross and Blue Shield Virginia prior authorization, page 51

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
92945	Percutaneous transluminal revascularization of chronic total occlusion, single coronary artery, coronary artery branch, or coronary artery bypass graft, and/or subtended major coronary artery branches of the bypass graft, any combination of intracoronary stent, atherectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
92972	Percutaneous transluminal coronary lithotripsy (List separately in addition to code for primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93145	Interrogation device evaluation (in person), carotid sinus baroreflex activation therapy (BAT) modulation system including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93150	Therapy activation of implanted phrenic nerve stimulator system, including all interrogation and programming	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93151	Interrogation and programming (minimum one parameter) of implanted phrenic nerve stimulator system	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93152	Interrogation and programming of implanted phrenic nerve stimulator system during polysomnography	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93153	Interrogation without programming of implanted phrenic nerve stimulator system	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93228	External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93229	External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93264	Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure recordings, interpretation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93303	Transthoracic Echocardiography, Congenital Cardiac Anomalies; Complete	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93304	Transthoracic Echocardiography, Congenital Cardiac Anomalies; Follow-Up/Limited Study	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93306	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, com	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93307	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, com	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93308	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, fol	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93312	Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 57 Original policy
93313	Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93314	Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image acq	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93315	Echocardiography, Transesophageal, Congenital Anomalies; W/Probe, Image, Intepretation & Report	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93316	Echocardiography, Transesophageal, Congenital Anomalies; Transesophageal Probe Placement Only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93317	Echocardiography, Transesophageal, Congenital Anomalies; Image, Interpretation & Report	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93350	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, dur	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93351	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93454	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93455	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; wit	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93456	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; wit	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93457	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; wit	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93458	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; wit	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93459	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; wit	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93460	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; wit	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93461	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; wit	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93580	Perc Transcatheter Closure, Congenital Interatrial Communication W/Implant	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93600	Bundle Of His Recording	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93602	Intra-Atrial Recording	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93603	Right Ventricular Recording	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93609	Intraventricular &/Or Intra-Atrial Mapping, Tachycardia Site(S) W/Catheter Manipulation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93613	Intracardiac Electrophysiologic 3-Dimensional Mapping	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93619	Electrophys Eval, W/Right Atrial/Ventricular Pace/Recording, Insertion Cath, W/O Arrhyth Induction	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93620	Electrophys Eval, Insert Cath, W/Arrhyth Induction; W/Right Atrial/Ventricular Pace/Record	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93621	Electrophys Eval, Insert Cath, W/Arrhyth Induction; W/Lt Atrial Pace/Record	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93622	Electrophys Eval, Insert Cath, W/Arrythmia Induction; W/Lt Vent Pace/Record	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93624	Electrophys, Follow-Up Study W/Pacing & Recording W/Arrhyth Induction	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93640	Electrophys Eval, Single/Dual Pacing Cardio/Defib Leads, Initial Implant/Replace	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93641	Electrophys Eval, Single/Dual Pacing Cardio/Defib Leads, Initial Implant/Replace; W/Pulse Generator	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93650	Intracardiac Catheter Ablation, Atrioventricular Node Function/Conduction	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93653	Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atri	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93654	Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atri	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93656	Comprehensive electrophysiologic evaluation with transseptal catheterizations, insertion and repositioning of multiple electrode catheters, induction or attempted induction of	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93657	Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolati	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93701	Bioimpedance-derived physiologic cardiovascular analysis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy

Sources

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