Anthem Blue Cross and Blue Shield Virginia prior authorization, page 59

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
E0737	Transcutaneous tibial nerve stimulator, controlled by phone application	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0738	Upper extremity rehabilitation system providing active assistance to facilitate muscle re- education, includes microprocessor, all components and accessories	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0739	Rehabilitation system with interactive interface providing active assistance in rehabilitation therapy, includes all components and accessories, motors, microprocessors, senso	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0745	Neuromuscular Stim For Shock	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0746	Electromyograph Biofeedback	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0748	Elec Osteogen Stim Spinal	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0760	Osteogen Ultrasound Stimltor	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0761	Non-Thermal Pulsed High Frequency Radiowaves, High Peak Power Electrom	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 64 Original policy
E0762	Transcutaneous electrical joint stimulation device system, includes all accessories	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E0764	Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E0769	Electric wound treatment dev	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E0770	Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, n	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E0782	Non-Programble Infusion Pump	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E0783	Programmable Infusion Pump	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E0786	Implantable Pump Replacement	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E0986	Manual wheelchair accessory, power assist system	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1002	Wheelchair accessory, power seating system, tilt only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1003	Wheelchair accessory, power seating system, recline only, without shear	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1004	Wheelchair accessory, power seating system, recline only, with mechanical shear	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1005	Wheelchair accessory, power seatng system, recline only, with power shear	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1006	Wheelchair accessory, power seating system, combination tilt and recline, w/o shear reduction	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1007	Wheelchair accessory, power seating system, combination tilt and recline, with manual shear reduction	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1008	Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1009	Wheelchair accessory, addition to power seating system, mechanically linked leg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1010	Wheelchair accessory, addition to power seating system, power leg elevation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1230	Power Operated Vehicle	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1239	Ped power wheelchair NOS	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1801	Static progressive stretch/patient actualized serial stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and ac	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1806	Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1811	Static progressive stretch/patient actualized serial stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and acc	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1816	Static progressive stretch/patient actualized serial stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and ac	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1841	Static progressive stretch/patient actualized serial stretch shoulder device, with or without range of motion adjustment, includes all components and accessories	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E1905	Virtual reality cognitive behavioral therapy device (cbt), including pre-programmed therapy software	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E2298	Complex rehabilitative power wheelchair accessory, power seat elevation system, any type	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
E3200	Gait modulation system, rhythmic auditory stimulation, including restricted therapy software, all components and accessories, prescription only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0068	Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, and/or inotropic infusion drug(s) for each infusion drug ad	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0069	Professional services for the administration of subcutaneous immunotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0070	Professional services for the administration of chemotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0088	Professional services, initial visit, for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion dr	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0089	Professional services, initial visit, for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administrat	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0090	Professional services, initial visit, for the administration of intravenous chemotherapy or other highly complex infusion drug or biological for each infusion drug administrat	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0123	Screen Cerv/Vag Thin Layer	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0124	Screen C/V Thin Layer By Md	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0141	Scr C/V Cyto,Autosys And Md	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0143	Scr C/V Cyto,Thinlayer,Rescr	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0144	Scr C/V Cyto,Thinlayer,Rescr	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0145	Scr C/V Cyto,Thinlayer,Rescr	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0147	Scr C/V Cyto, Automated Sys	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0148	Scr C/V Cyto, Autosys, Rescr	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0255	Current Perception Threshold/Sensory Nerve Conduction Test, Per Limb	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy

Sources

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