Anthem Blue Cross and Blue Shield Virginia prior authorization, page 58

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
D9222	deep sedation/general anesthesia - first 15 minutes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D9223	deep sedation/general anesthesia - each subsequent 15 minute increment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 63 Original policy
D9950	occlusion analysis - mounted case	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
D9951	occlusal adjustment - limited	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
D9952	occlusal adjustment - complete	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0217	Water Circ Heat Pad W Pump	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0218	Fluid circulating cold pad with pump, any type	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0236	Pump For Water Circulating P	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0470	Respiratory assist device, bi-level pressure capability, without backup rate	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0471	Respiratory assist device, bi-level pressure capability, with back-up rate	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0481	Intrapulmonary percussive ventilation system and related accessories	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0485	Oral device/appliance used to reduce upper airway collapsibility, adjustable or non- adjustable, prefabricated, includes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0486	Oral device/appliance used to reduce upper airway collapsibility, adjustable or non- adjustable, custom fabricated, inclu	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0491	Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by hard	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0492	Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, controlled by phone application	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0493	Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by phon	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0530	Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any type	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0561	Humidifier, non-heated, used with positive airway pressure device	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0562	Humidifier, heated, used with positive airway pressure device	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0601	Continuous positive airway pressure (cpap) device	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0650	Pneuma Compresor Non-Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0651	Pneum Compressor Segmental	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0652	Pneum Compres W/Cal Pressure	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0655	Pneumatic Appliance Half Arm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0656	Segmental pneumatic appliance for use with pneumatic compressor, trunk	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0657	Segmental pneumatic appliance for use with pneumatic compressor, chest	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0658	Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full arms and chest	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0660	Pneumatic Appliance Full Leg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0665	Pneumatic Appliance Full Arm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0666	Pneumatic Appliance Half Leg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0667	Seg Pneumatic Appl Full Leg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0668	Seg Pneumatic Appl Full Arm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0669	Seg Pneumatic Appli Half Leg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0670	Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0671	Pressure Pneum Appl Full Leg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0672	Pressure Pneum Appl Full Arm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0673	Pressure Pneum Appl Half Leg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0676	INTERMITTENT LIMB COMPRESSION DEVICE (INCLUDES ALL ACCESSORIES), NOT OTHERWISE	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0677	Non-pneumatic sequential compression garment, trunk	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0678	Non-pneumatic sequential compression garment, full leg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0679	Non-pneumatic sequential compression garment, half leg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0680	Non-pneumatic compression controller with sequential calibrated gradient pressure	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0681	Non-pneumatic compression controller without calibrated gradient pressure	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0682	Non-pneumatic sequential compression garment, full arm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0683	Non-pneumatic, non-sequential, peristaltic wave compression pump	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0721	Transcutaneous electrical nerve stimulatory, stimulates nerves in the auricular region	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0732	Cranial electrotherapy stimulation (ces) system, any type	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0734	External upper limb tremor stimulator of the peripheral nerves of the wrist	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0735	Non-invasive vagus nerve stimulator	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0736	Transcutaneous tibial nerve stimulator	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 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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