Anthem Blue Cross and Blue Shield Virginia prior authorization, page 66

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
J9026	Injection, tarlatamab-dlle, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9028	Injection, nogapendekin alfa inbakicept-pmln, for intravesical use, 1 microgram	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9029	Intravesical instillation, nadofaragene firadenovec-vncg, per therapeutic dose	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9032	Injection, belinostat, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9033	Injection, bendamustine hydrochloride, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9034	Injection, bendamustine hcl (bendeka), 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9035	Bevacizumab injection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9036	Injection, bendamustine hydrochloride, (Belrapzo), 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9039	Injection, blinatumomab, 1 microgram	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9042	Injection, brentuximab vedotin, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9043	Injection, cabazitaxel, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9047	Injection, carfilzomib, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9053	Injection, belantamab mafodotin-blmf, 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9055	Cetuximab injection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9056	Injection, bendamustine hydrochloride (vivimusta), 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9057	Injection, copanlisib, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9061	Injection, amivantamab-vmjw, 2 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9062	Injection, amivantamab 5 mg and hyaluronidase-lpuj	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9063	Injection, mirvetuximab soravtansine-gynx, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9064	Injection, cabazitaxel (Sandoz), not therapeutically equivalent to J9043, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9118	Injection, calaspargase pegol-mknl, 10 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9119	Injection, cemiplimab-rwlc, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9144	Injection, daratumumab, 10 mg and hyaluronidase-fihj	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9145	Injection, daratumumab, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9161	Injection, denileukin diftitox-cxdl, 1 mcg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9173	Injection, durvalumab, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9176	Injection, elotuzumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9177	Injection, enfortumab vedotin-ejfv, 0.25 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9179	Injection, eribulin mesylate, 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9183	Gemcitabine intravesical system, 225 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9202	Goserelin Acetate Implant	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9203	Injection, gemtuzumab ozogamicin, 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9207	Injection, ixabepilone, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9210	Injection, emapalumab-lzsg, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9216	Injection, interferon, gamma-1B, 3 million units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9217	Leuprolide Acetate Suspnsion	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9223	Injection, lurbinectedin, 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9226	Histrelin implant (supprelin LA), 50 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9227	Injection, isatuximab-irfc, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9228	Injection, ipilimumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9229	Injection, inotuzumab ozogamicin, 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9248	Injection, melphalan (Hepzato), 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9262	Injection, omacetaxine mepesuccinate, 0.01 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9264	Injection, paclitaxel protein-bound particles, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9266	Injection, pegaspargase, per single dose vial	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9269	Injection, tagraxofusp-erzs, 10 micrograms	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9271	Injection, pembrolizumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 71 Original policy
J9272	Injection, dostarlimab-gxly, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9273	Injection, tisotumab vedotin-tftv, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9274	Injection, tebentafusp-tebn, 1 microgram	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 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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