Anthem Blue Cross and Blue Shield Virginia prior authorization, page 57

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
C9257	Injection, bevacizumab, 0.25 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9352	Microporous collagen implantable tube (NeuraGen Nerve Guide), per cm length	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9353	Microporous collagen implantable slit tube (NeuraWrap Nerve Protector), per cm length	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9354	Acellular pericardial tissue matrix of nonhuman origin (Veritas), per sq cm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9355	Collagen nerve cuff (NeuroMatrix), per 0.5 cm length	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9356	Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector Sheet), per sq cm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9358	Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9359	Porous purified collagen matrix bone void filler (Integra Mozaik Osteoconductive Scaffold Putty, Integra OS Osteoconductive Scaffold Putty), per 0.5 cc	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9361	Collagen matrix nerve wrap (NeuroMend Collagen Nerve Wrap), per 0.5 cm length	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9362	Porous purified collagen matrix bone void filler (Integra Mozaik Osteoconductive Scaffold Strip), per 0.5 cc	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9363	Skin substitute (Integra Meshed Bilayer Wound Matrix), per square cm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9364	Porcine implant, Permacol, per sq cm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9600	Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9601	Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (list	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9602	Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9603	Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary art	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9604	Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9605	Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9607	Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluti	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9608	Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluti	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9727	Insertion of implants into the soft palate; minimum of 3 implants	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9734	Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (mr) guidance	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9762	Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9763	Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9764	Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, includes angioplasty within the sam	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9765	Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, and transluminal stent placement(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9766	Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and atherectomy, includes angioplast	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9767	Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and transluminal stent placement(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9772	Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy, includes angioplasty within the same vessel (s), when perfo	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9773	Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9774	Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9775	Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includ	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9781	Arthroscopy, shoulder, surgical; with implantation of subacromial spacer (e.g., balloon), includes debridement (e.g., limited or extensive), subacromial decompression, acromio	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9785	Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9796	Repair of enterocutaneous fistula small intestine or colon (excluding anorectal fistula) with plug (e.g., porcine small intestine submucosa [SIS])	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9807	Nerve stimulator, percutaneous, peripheral (e.g., sprint peripheral nerve stimulation system), including electrode and all disposable system components, non-opioid medical dev	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9808	Nerve cryoablation probe (e.g., cryoice, cryosphere, cryosphere max, cryoice cryosphere, cryoice cryo2), including probe and all disposable system components, non-opioid medic	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
C9809	Cryoneurolysis needle (e.g., iovera system), including needle/tip and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid med	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D7940	osteoplasty - for orthognathic deformities	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D7941	osteotomy - mandibular rami	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D7943	osteotomy - mandibular rami with bone graft; includes obtaining the graft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D7944	osteotomy - segmented or subapical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D7945	osteotomy - body of mandible	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D7946	LeFort I (maxilla - total)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D7947	LeFort I (maxilla - segmented)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D7948	LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D7949	LeFort II or LeFort III - with bone graft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D7950	osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D7995	synthetic graft - mandible or facial bones, by report	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D7996	implant-mandible for augmentation purposes (excluding alveolar ridge), by report	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy

Sources

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