Anthem Blue Cross and Blue Shield Virginia prior authorization, page 55

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
A7029	Nasal pillows for combination oral/nasal mask, replacement only, pair	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A7030	Full Face Mask Used With Positive Airway Pressure Device, Each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A7031	Face Mask Interface, Replacement For Full Face Mask, Each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A7032	Cushion for use on nasal mask interface, replacement only, each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A7033	Pillow for use on nasal cannula type interface, replacement only, pair	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A7034	Nasal Interface (Mask Or Cannula Type) Used With Positive Airway Press	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A7035	Headgear Used With Positive Airway Pressure Device	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A7036	Chinstrap Used With Positive Airway Pressure Device	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A7037	Tubing Used With Positive Airway Pressure Device	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A7038	Filter, Disposable, Used With Positive Airway Pressure Device	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A7039	Filter, Non Disposable, Used With Positive Airway Pressure Device	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A7044	Oral Interface Used With Positive Airway Pressure Device, Each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A7045	Repl exhalation port for PAP	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A7046	Water chamber for humidifier, used with positive airway pressure device, replacement, each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A9268	Programmer for transient, orally ingested capsule	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A9269	Programmable, transient, orally ingested capsule, for use with external programmer, per month	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A9279	Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A9513	Lutetium Lu 177, dotatate, therapeutic, 1 mCi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A9543	Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A9606	Radium RA-223 dichloride, therapeutic, per UCI	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
A9607	Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4164	Parenteral 50% Dextrose Solu	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4168	Parenteral Sol Amino Acid 3.	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4176	Parenteral Sol Amino Acid 7	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4178	Parenteral Sol Amino Acid >	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4180	Parenteral Sol Carb > 50%	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4185	Parenteral nutrition solution, not otherwise specified, 10 grams lipids	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4187	Omegaven, 10 g lipids	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4189	Parenteral Sol Amino Acid &	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4193	Parenteral Sol 52-73 Gm Prot	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4197	Parenteral Sol 74-100 Gm Pro	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4199	Parenteral Sol > 100gm Prote	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4216	Parenteral Nutrition Additiv	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4220	Parenteral Supply Kit Premix	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4222	Parenteral Supply Kit Homemi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B4224	Parenteral Administration Ki	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B5000	Parenteral Sol Renal-Amirosy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B5100	Parenteral Sol Hepatic-Fream	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B5200	Parenteral Sol Stres-Brnch C	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B9004	Parenteral Infus Pump Portab	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 61 Original policy
B9006	Parenteral Infus Pump Statio	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1605	Pacemaker, leadless, dual chamber (right atrial and right ventricular implantable components), rate-responsive, including all necessary components for implantation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1721	Cardioverter-defibrillator, dual chamber (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1722	Cardioverter-defibrillator, single chamber (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1726	Catheter, balloon dilatation, nonvascular	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1734	Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1735	Catheter(s), intravascular for renal denervation, radiofrequency, including all single use system components	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1736	Catheter(s), intravascular for renal denervation, ultrasound, including all single use system components	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1763	Connective tissue, nonhuman (includes synthetic)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1764	Event recorder, cardiac (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy

Sources

Disclaimer

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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