Anthem Blue Cross and Blue Shield Virginia prior authorization, page 6

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
0409U	Oncology (solid tumor), DNA (80 genes) and RNA (36 genes), by next-generation sequencing from plasma, including single nucleotide variants, insertions/deletions, copy number a	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy
0410T	Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy
0410U	Oncology (pancreatic), DNA, whole genome sequencing with 5-hydroxymethylcytosine enrichment, whole blood or plasma, algorithm reported as cancer detected or not detected	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy
0411T	Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy
0411U	Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication ana	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy
0412T	Removal of permanent cardiac contractility modulation system; pulse generator only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy
0412U	Beta amyloid, AB42/40 ratio, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and qualitative ApoE isoform- specific prot	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy
0413T	Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy
0413U	Oncology (hematolymphoid neoplasm), optical genome mapping for copy number alterations, aneuploidy, and balanced/complex structural rearrangements, DNA from blood or bone marr	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy
0414T	Removal and replacement of permanent cardiac contractility modulation system pulse generator only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy
0414U	Oncology (lung), augmentative algorithmic analysis of digitized whole slide imaging for 8 genes (ALK, BRAF, EGFR, ERBB2, MET, NTRK1-3, RET, ROS1), and KRAS G12C and PD-L1, if	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy
0415T	Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy
0416T	Relocation of skin pocket for implanted cardiac contractility modulation pulse generator	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy
14041	Adjacent Tissue Transfer, Forehead/Cheeks/Chin/Mouth/Neck/Axillae/Genitalia/Hands/Feet;10.1-30.0sqcm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 10 Original policy
14060	Adjacent Tissue Transfer/Rearrangement, Eyelids/Nose/Ears/Lips; Defect 10 Sq Cm/<	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 10 Original policy
14061	Adjacent Tissue Transfer/Rearrangement, Eyelids/Nose/Ears/Lips; Defect 10.1-30.0 Sq Cm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 10 Original policy
15011	Harvest of skin for autograft; first	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 10 Original policy
15013	Preparation of skin autograft, requiring enzymatic processing,; first 25 sq cm or less	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 10 Original policy
15015	Application of skin autograft; first 480 sq cm or less	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 10 Original policy
15017	Application of skin autograft; first 480 sq cm or less	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 10 Original policy
15150	Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 10 Original policy
15151	Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 10 Original policy
15155	Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 10 Original policy
15271	Application Of Skin Substitute Graft To Trunk, Arms, Legs, Total Wound Surface Area Up To 100 Sq Cm; First 25 Sq Cm Or Less Wound Surface Area	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15273	Application Of Skin Substitute Graft To Trunk, Arms, Legs, Total Wound Surface Area Greater Than Or Equal To 100 Sq Cm; First 100 Sq Cm Wound Surface Area, Or 1% Of Body Area	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15275	Application Of Skin Substitute Graft To Face, Scalp, Eyelids, Mouth, Neck, Ears, Orbits, Genitalia, Hands, Feet, And/Or Multiple Digits, Total Wound Surface Area Up To 100 Sq	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15277	Application Of Skin Substitute Graft To Face, Scalp, Eyelids, Mouth, Neck, Ears, Orbits, Genitalia, Hands, Feet, And/Or Multiple Digits, Total Wound Surface Area Greater Than	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15771	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15773	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15775	Punch Graft, Hair Transplant; 1-15 Punch Grafts	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15776	Punch Graft, Hair Transplant; > 15 Punch Grafts	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15780	Dermabrasion; Total Face	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15781	Dermabrasion; Segmental, Face	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15782	Dermabrasion; Regional, Other Than Face	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15783	Dermabrasion; Superficial, Any Site	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15786	Abrasion; Single Lesion	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15788	Chemical Peel, Facial; Epidermal	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15789	Chemical Peel, Facial; Dermal	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15792	Chemical Peel, Nonfacial; Epidermal	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15793	Chemical Peel, Nonfacial; Dermal	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15820	Blepharoplasty, Lower Eyelid	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15821	Blepharoplasty, Lower Eyelid; W/Extensive Herniated Fat Pad	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15822	Blepharoplasty, Upper Eyelid	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15823	Blepharoplasty, Upper Eyelid; W/Excessive Skin Weighting Down Lid	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15824	Rhytidectomy; Forehead	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15825	Rhytidectomy; Neck W/Platysmal Tightening (Platysmal Flap, P-Flap)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15826	Rhytidectomy; Glabellar Frown Lines	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15828	Rhytidectomy; Cheek, Chin, & Neck	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15829	Rhytidectomy; Superficial Musculoaponeurotic System (Smas) Flap	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy
15830	Excision, excessive skin and subcutaneous tissue (incluedes lipectomy, abdomen, infraumbilical panniculectomy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy

Sources

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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.

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