Anthem Blue Cross and Blue Shield Virginia prior authorization, page 54
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 |
|---|---|---|
| A0431 | Rotary Wing Air Transport | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A0435 | Fixed Wing Air Mileage | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A0436 | Rotary Wing Air Mileage | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2001 | Innovamatrix ac, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2002 | Mirragen advanced wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2004 | Xcellistem, 1 mg/Original description: Miscellaneous with Motor <27.85, without comorbidities,10/2019 description: Miscellaneous M <46.50 and A >=77.50.,witho | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2005 | Microlyte matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2006 | Novosorb synpath dermal matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2007 | Restrata, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2008 | Theragenesis, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2009 | Symphony, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2010 | Apis, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2011 | Supra sdrm, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2012 | Suprathel, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2013 | Innovamatrix fs, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2014 | Omeza collagen matrix or omeza complete matrix, per 100 mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2015 | Phoenix wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2016 | Permeaderm b, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2017 | PermeaDerm Glove, each | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2018 | Permeaderm c, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2019 | Kerecis omega3 marigen shield, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2020 | Ac5 advanced wound system (ac5) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2021 | Neomatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2022 | Innovaburn or innovamatrix xl, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2023 | InnovaMatrix PD, 1 mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2024 | Resolve matrix or xenopatch, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2025 | Miro3d, per cubic centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2026 | Restrata MiniMatrix, 5 mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2027 | Matriderm, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2028 | Micromatrix flex, per mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2029 | Mirotract wound matrix sheet, per cubic centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2030 | Miro3D fibers, per mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2031 | Mirodry wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2032 | Myriad matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy |
| A2033 | Myriad Morcells, 4 mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A2034 | Foundation drs solo, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A2035 | Corplex P or Theracor P or Allacor P, per mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A4100 | Non-sheet form skin substitute, fda cleared as a device, not otherwise specified (list in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A4438 | Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A4468 | Exsufflation belt, includes all supplies and accessories | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A4540 | Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A4542 | Supplies and accessories for external upper limb tremor stimulator of the peripheral nerves of the wrist | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A4543 | Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A4545 | Supplies and accessories for external tibial nerve stimulator (e.g., socks, gel pads, electrodes, etc.), needed for one month | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A4596 | Cranial electrotherapy stimulation (ces) system supplies and accessories, per month | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A4600 | SLEEVE FOR INTERMITTENT LIMB COMPRESSION DEVICE, REPLACEMENT ONLY, EACH | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A4604 | Tubing with integrated heating element for use with positive airway pressure device | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A4649 | Surgical Supplies; miscellaneous | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A7027 | Combination oral/nasal mask, used with continuous positive airway pressure | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |
| A7028 | Oral cushion for combination oral/nasal mask, replacement only, each | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy |