Anthem Blue Cross and Blue Shield Virginia prior authorization, page 7
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
| Code | Description | Source |
|---|---|---|
| 15832 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15833 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15834 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15835 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15836 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15837 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15838 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15839 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15840 | Graft, Facial Nerve Paralysis; Free Fascia Graft (W/Obtaining Fascia) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15841 | Graft, Facial Nerve Paralysis; Free Muscle Graft (W/Obtaining Graft) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15842 | Graft, Facial Nerve Paralysis; Free Muscle Flap, Microsurgical Technique | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15845 | Graft, Facial Nerve Paralysis; Regional Muscle Transfer | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15876 | Suction Assisted Lipectomy; Head & Neck | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15877 | Suction Assisted Lipectomy; Trunk | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15878 | Suction Assisted Lipectomy; Upper Extremity | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 15879 | Suction Assisted Lipectomy; Lower Extremity | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 17106 | Destruction, Cutaneous Vascular Proliferative Lesions; < 10 Sq Cm | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 17107 | Destruction, Cutaneous Vascular Proliferative Lesions; 10.0-50.0 Sq Cm | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 17108 | Destruction, Cutaneous Vascular Proliferative Lesions; > 50.0 Sq Cm | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 17380 | Electrolysis epilation, each 30 minutes | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 19105 | Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 19296 | Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial rad | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 19300 | Mastectomy for gynecomastia | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 19316 | Mastopexy | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 19318 | Breast reduction | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 19325 | Breast augmentation with implant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 19328 | Removal of intact breast implant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 19330 | Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 19340 | Insertion of breast implant on same day of mastectomy (ie, immediate) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 11 Original policy |
| 19342 | Insertion or replacement of breast implant on separate day from mastectomy | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 19350 | Nipple/Areola Reconstruction | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 19355 | Correction, Inverted Nipples | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 19357 | Tissue expander placement in breast reconstruction, including subsequent expansion(s) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 19361 | Breast reconstruction; with latissimus dorsi flap | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 19364 | Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 19367 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 19368 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 19369 | Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 19380 | Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re- inset of flaps in autologous reconstruction or significant capsular revision comb | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 19396 | Preparation, Moulage, Custom Breast Implant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 20555 | Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (a | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 20560 | Needle insertion(s) without injection(s); 1 or 2 muscle(s) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 20561 | Needle insertion(s) without injection(s); 3 or more muscles | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 20605 | Arthrocentesis, Aspiration &/Or Injection; Intermediate Joint/Bursa | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 20606 | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound gu | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 20930 | Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 20931 | Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 20932 | Allograft, includes templating, cutting, placement and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone (List separately in a | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 20933 | Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (ie, hemicylindrical) (List separately in addition | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |
| 20934 | Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (ie, cylindrical) (List separately in addition to code for prim | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy |