Anthem Blue Cross and Blue Shield Virginia prior authorization, page 56

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
C1767	Generator, neurostimulator (implantable), nonrechargeable	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1772	Infusion pump, programmable (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1777	Lead, cardioverter-defibrillator, endocardial single coil (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1778	Lead, neurostimulator (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1785	Pacemaker, dual chamber, rate-responsive (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1786	Pacemaker, single chamber, rate-responsive (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1787	Patient programmer, neurostimulator	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1789	Prosthesis, breast (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1813	Prosthesis, penile, inflatable	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1815	Prosthesis, urinary sphincter (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1816	Receiver and/or transmitter, neurostimulator (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1820	Generator, neurostimulator (implantable), with rechargeable battery and charging system	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1821	Interspinous process distraction device (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1822	Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1823	Generator, neurostimulator (implantable), non-rechargeable, with transvenous sensing and stimulation leads	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1824	Generator, cardiac contractility modulation (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1825	Generator, neurostimulator (implantable), non-rechargeable with carotid sinus baroreceptor stimulation lead(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1832	Autograft suspension, including cell processing and application, and all system components	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1833	Monitor, cardiac, including intracardiac lead and all system components (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1839	Iris prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1878	Material for vocal cord medialization, synthetic (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1882	Cardioverter-defibrillator, other than single or dual chamber (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1883	Adaptor/extension, pacing lead or neurostimulator lead (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1895	Lead, cardioverter-defibrillator, endocardial dual coil (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C1896	Lead, cardioverter-defibrillator, other than endocardial single or dual coil (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C2614	Probe, percutaneous lumbar discectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C2619	Pacemaker, dual chamber, nonrate-responsive (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C2621	Pacemaker, other than single or dual chamber (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C2622	Prosthesis, penile, noninflatable	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C2624	Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C2626	Infusion pump, nonprogrammable, temporary (implantable)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C7513	Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C7514	Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C7515	Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C7517	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, with iliac and/or femoral artery angiograph	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C7531	Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal angioplasty with intravascular ultrasound (initial noncoro	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C7534	Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with atherectomy, includes angioplasty within the same vessel, when performe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C7535	Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal stent placement(s), includes angioplasty within the same v	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C7538	Insertion of new or replacement of permanent pacemaker with ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricul	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C7539	Insertion of new or replacement of permanent pacemaker with atrial and ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for lef	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C7540	Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, dual lead system, with insertion of pacing electrode, cardiac venous system, for	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C7552	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 62 Original policy
C7553	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 62 Original policy
C8002	Preparation of skin cell suspension autograft, automated, including all enzymatic processing and device components (do not report with manual suspension preparation)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C8003	Implantation of medial knee extraarticular implantable shock absorber spanning the knee joint from distal femur to proximal tibia, open, includes measurements, positioning and	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C8903	Magnetic resonance imaging with contrast, breast; unilateral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 62 Original policy
C8905	Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C8906	Magnetic resonance imaging with contrast, breast; bilateral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C8908	Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9047	Injection, caplacizumab-yhdp, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy

Sources

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