Anthem Blue Cross and Blue Shield Virginia prior authorization, page 60

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
G0260	Injection Procedure For Sacroiliac Joint; Provision Of Anesthetic, Ste	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0277	Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0283	Electrical Stimulation (Unattended), To One Or More Areas For Indicati	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0289	Arthroscopy, Knee, Surgical, For Removal Of Loose Body, Foreign Body	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0295	Electromagnetic Stimulation, To One Or More Areas	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0300	Direct skilled nursing services of a license practical nurse (LPN) in the home health or hospice setting, each 15 minutes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0306	Complete cbc, automated (hgb, hct, rbc, wbc, without platelet count) and automated wbc diff count	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0307	Complete (cbc), automated (hgb, hct, rbc, wbc; without platelet count)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0328	Fecal blood scrn immunoassay	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0330	Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia ca	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0339	Robot lin-radsurg com, first	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0340	Robt lin-radsurg fractx 2-5	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0341	Percutaneous islet celltrans	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 65 Original policy
G0342	Laparoscopy islet cell trans	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0343	Laparotomy islet cell transp	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0398	Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart r	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0399	Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0400	Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0416	Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method, 10-20 specimens	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0428	Collagen Meniscus Implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0429	Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0432	Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique antibody, HIV-1 or HIV-2 scre	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0433	Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, antibody, HIV-1 or HIV-2, sc	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0435	Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0448	Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac v	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0458	Low dose rate (ldr) prostate brachytherapy services, composite rate	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0460	Autologous platelet rich plasma or other blood-derived product for non-diabetic chronic wounds/ulcers, including as applicable phlebotomy, centrifugation or mixing, and all ot	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0465	Autologous platelet rich plasma (PRP) or other blood-derived product for diabetic chronic wounds/ulcers, using an FDA-cleared device for this indication, (includes as applicab	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0490	Face-to-face home health nursing visit by a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) in an area with a shortage of home health agencies (services	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0494	Skilled services of a licensed practical nurse (lpn) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requ	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0495	Skilled services of a registered nurse (rn), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G0496	Skilled services of a licensed practical nurse (lpn), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G2082	Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care profes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G2083	Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care profes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G9143	Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G9840	RAS (KRAS and NRAS) gene mutation testing performed before initiation of anti-EGFR MoAb	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
G9841	RAS (KRAS and NRAS) gene mutation testing not performed before initiation of anti-EGFR MoAb	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
H0003	Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol and/or drugs	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
H0015	Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment p	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
H0017	Behavioral health; residential (hospital residential treatment program), without room and board, per diem	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
H0019	Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, pe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
H0035	Mental health partial hospitalization, treatment, less than 24 hours	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
H0047	Alcohol and/or other drug abuse services, not otherwise specified	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
H0048	Alcohol and/or other drug testing: collection and handling only, specimens other than blood	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
H0049	Alcohol and/or drug screening	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0129	Injection, abatacept, 10 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0174	Lecanemab-irmb, for intravenous injection, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0175	Injection, donanemab-azbt, 2 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0177	Injection, aflibercept HD, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy

Sources

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