Anthem Blue Cross and Blue Shield Virginia prior authorization, page 52

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
93880	Duplex Scan, Extracranial Arteries; Complete Bilat Study	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93882	Duplex Scan, Extracranial Arteries; Unilat/Limited Study	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93922	Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93923	Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93924	Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing (ie, bidirectional Doppler waveform or volume plethysmography recor	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93925	Duplex Scan, Lower Extremity Arteries/Arterial Bypass Grafts; Complete Bilat Study	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93926	Duplex Scan, Lower Extremity Arteries/Arterial Bypass Grafts; Unilat/Limited Study	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93930	Duplex Scan, Upper Extremity Arteries/Arterial Bypass Grafts; Complete Bilat Study	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93931	Duplex Scan, Upper Extremity Arteries/Arterial Bypass Grafts; Unilat/Limited Study	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93978	Duplex Scan, Aorta, Inferior Vena Cava, Iliac Vasculature/Bypass Grafts; Complete Study	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
93979	Duplex Scan, Aorta, Inferior Vena Cava, Iliac Vasculature/Bypass Grafts; Unilat/Limited	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
94667	Chest Wall Manipulation, Facilitate Lung Function; Initial Demo &/Or Eval	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
95782	Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
95783	Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
95800	Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
95801	Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
95805	Multiple Sleep Latency Test, Multiple Trails	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
95806	Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
95807	Sleep Study, Attended	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
95808	Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
95810	Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
95811	Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel v	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 58 Original policy
95905	Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, eac	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
95921	Testing, Autonomic Nervous System; Cardiovagal Innervation Parasympathetic	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
95923	Testing, Autonomic Nervous System; Sudomotor	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
95965	Magnetoencephalography (Meg), Record & Analysis; For Spontaneous Brain Magnetic Activity	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
95966	Magnetoencephalography (Meg), Record & Analysis; For Evoked Magnetic Fields, Single Modality	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
95976	Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
95977	Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
96001	Comprehensive computer-based motion analysis by video-taping and 3D kinematics; with dynamic plantar pressure measuremen	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
96365	Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
96372	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
96904	Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history o	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
96931	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
96932	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, first lesion	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
96933	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, first lesion	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
96934	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each additional lesion (List separately i	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
96935	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, each additional lesion (List separately in addition to code for pr	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
96936	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, each additional lesion (List separately in addition to cod	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
97010	Application of a modality to 1 or more areas; hot or cold packs	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
97012	Application of a modality to 1 or more areas; traction, mechanical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
97016	Application of a modality to 1 or more areas; vasopneumatic devices	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
97018	Application of a modality to 1 or more areas; paraffin bath	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
97022	Application of a modality to 1 or more areas; whirlpool	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
97024	Application of a modality to 1 or more areas; diathermy (eg, microwave)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
97026	Application of a modality to 1 or more areas; infrared	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
97028	Application of a modality to 1 or more areas; ultraviolet	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
97032	Application, Modality 1+ Areas; Electrical Stimulation (Manual), Each 15 Min	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy
97033	Application of a modality to 1 or more areas; iontophoresis, each 15 minutes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 59 Original policy

Sources

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