Anthem Blue Cross and Blue Shield Virginia prior authorization, page 69

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
K0857	POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 73 Original policy
K0858	POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POU	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 73 Original policy
K0859	POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 73 Original policy
K0860	POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 60	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 73 Original policy
K0861	POWER WHEELCHAIR, GROUP 3 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCL	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 73 Original policy
K0862	POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 P	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 73 Original policy
K0863	POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 73 Original policy
K0864	POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 PO	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0868	POWER WHEELCHAIR, GROUP 4 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0869	POWER WHEELCHAIR, GROUP 4 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0870	POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0871	POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0877	POWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUD	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0878	POWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0879	POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POU	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0880	POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT 451 TO 600 POUNDS	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0884	POWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCL	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0885	POWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR, WEIGHT CAPACITY UP TO AND INCLUDING 300 POUND	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0886	POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 P	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0890	POWER WHEELCHAIR, GROUP 5 PEDIATRIC, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLU	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0891	POWER WHEELCHAIR, GROUP 5 PEDIATRIC, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INC	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0899	Power mobility device, not coded by DME PDAC or does not meet criteria	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K0900	Customized durable medical equipment, other than wheelchair	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K1027	Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
K1030	External recharging system for battery (internal) for use with implanted cardiac contractility modulation generator, replacement only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8045	Auricular Prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8600	Implant Breast Silicone/Eq	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8607	Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8614	COCHLEAR DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTS	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8619	Cochlear Implant, External Speech Processor And Controller, Integrated System, Replacement	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8627	Cochlear Implant, External Speech Processor, Component, Replacement	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8628	Cochlear Implant, External Controller Component, Replacement	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8678	Electrical stimulator supplies (external) for use with implantable neurostimulator, per month	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8679	Implantable neurostimulator, pulse generator, any type	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8680	Implantable neurostimulator electrode, each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8681	Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8682	Implantable neurostimulator radiofrequency receiver	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8683	Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8686	Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8688	Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8690	AUDITORY OSSEOINTEGRATED DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTS	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8691	Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8692	Auditory Osseointegrated Device, External Sound Processor, Used Without Osseointegration, Body Worn, Includes Headband O	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8693	Auditory osseointegrated device abutment, any length, replacement only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8694	Auditory osseointegrated device, transducer/actuator, replacement only, each	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
L8702	Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessorie	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
P2028	Cephalin Floculation Test	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy
P2029	Congo Red Blood Test	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 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.

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