Anthem Blue Cross and Blue Shield Virginia prior authorization, page 64

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
J2507	Injection, pegloticase, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2508	Injection, pegunigalsidase alfa-iwxj, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2510	Penicillin G Procaine Inj	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2540	Penicillin G Potassium Inj	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2562	Injection, Plerixafor, 1 Mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2777	Injection, faricimab-svoa, 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2778	Injection, ranibizumab, 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2779	Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2781	Injection, pegcetacoplan, intravitreal, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2782	Injection, avacincaptad pegol, 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2786	Injection, reslizumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2787	Riboflavin 5'-phosphate, ophthalmic solution (photrexa viscous/photrexa), up to 3 ml	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2793	Injection, Rilonacept, 1 Mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2802	Injection, romiplostim, 1 microgram	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2820	Sargramostim Injection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2840	Injection, sebelipase alfa, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2941	Injection, somatropin, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2998	Injection, plasminogen, human-tvmh, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3032	Injection, eptinezumab-jjmr, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3055	Injection, talquetamab-tgvs, 0.25 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3060	Injection, taliglucerace alfa, 10 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3111	Injection, romosozumab-aqqg, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3241	Injection, teprotumumab-trbw, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3245	Injection, tildrakizumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3247	Injection, secukinumab, IV, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3262	Injection, tocilizumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3263	Injection, toripalimab-tpzi, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3285	Injection, treprostinil, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3304	Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3316	Injection, triptorelin, extended-release, 3.75 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3357	Ustekinumab, for subcutaneous injection, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3358	Ustekinumab, for intravenous injection, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3380	Injection, vedolizumab, IV, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3385	Injection, velaglucerase alfa, 100 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3391	Injection, atidarsagene autotemcel, per treatment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J3392	Injection, exagamglogene autotemcel, per treatment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J3393	Injection, betibeglogene autotemcel, per treatment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J3394	Injection, lovotibeglogene autotemcel, per treatment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J3397	Injection, vestronidase alfa-vjbk, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J3398	Injection, voretigene neparvovec-rzyl, 1 billion vector genomes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J3399	Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector genomes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J3401	Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10^9 pfu/ml vector genomes, per 0.1 ml	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J3402	Injection, remestemcel-l-rknd, per therapeutic dose	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J3403	Revakinagene taroretcel-lwey, per implant	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J3489	Injection, zoledronic acid, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J7170	Injection, emicizumab-kxwh, 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J7171	Injection, ADAMTS13, recombinant-krhn, 10 IU	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J7175	Injection, factor x, (human), 1 i.u.	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J7177	Injection, human fibrinogen concentrate (Fibryga), 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 Original policy
J7178	Injection, human fibrinogen concentrate, not otherwise specified, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 70 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.

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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