Anthem Blue Cross and Blue Shield Virginia prior authorization, page 70
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 |
|---|---|---|
| P2031 | Hair Analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy |
| P2033 | Blood Thymol Turbidity | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy |
| P2038 | Blood Mucoprotein | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy |
| P3000 | Screen Pap By Tech W Md Supv | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy |
| P3001 | Screening Pap Smear By Phys | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy |
| P7001 | Culture Bacterial Urine | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy |
| P9612 | Catheterize For Urine Spec | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy |
| P9615 | Urine Specimen Collect Mult | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy |
| Q0111 | Wet Mounts/ W Preparations | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy |
| Q0114 | Fern Test | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy |
| Q0115 | Post-Coital Mucous Exam | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy |
| Q2026 | Injection, Radiesse, 0.1ml | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy |
| Q2028 | Injection, sculptra, 0.5 mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 74 Original policy |
| Q2041 | Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q2042 | Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q2043 | Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q2053 | Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q2054 | Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q2055 | Idecabtagene vicleucel, up to 510 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, p | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q2056 | Ciltacabtagene autoleucel, up to 100 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q2057 | Afamitresgene autoleucel, including leukapheresis and dose preparation procedures, per therapeutic dose | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q2058 | Obecabtagene autoleucel, 10 up to 400 million cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per infusion | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q3001 | Brachytherapy Radioelements | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q3027 | Injection, interferon beta-1a, 1 mcg for intramuscular use | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q3028 | Injection, interferon beta-1a, 1 mcg for subcutaneous use | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4074 | Iloprost, Inhalation Solution, Fda-Approved Final Product, Non-Compounded, Administered Through Dme, Unit Dose Form, Up | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4081 | INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4101 | Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4102 | Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4103 | Oasis burn matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4104 | Integra bilayer matrix wound dressing (bmwd), per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4105 | Integra dermal regeneration template (drt) or integra omnigraft dermal regeneration matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4107 | Graftjacket, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4108 | Integra matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4110 | Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4111 | Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4113 | GRAFTJACKET XPRESS, injectable, 1cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4114 | Integra flowable wound matrix, injectable, 1 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4115 | Alloskin, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4116 | Alloderm, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4117 | Hyalomatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4118 | Matristem micromatrix, 1 mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4121 | Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4122 | Dermacell, dermacell awm or dermacell awm porous, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4123 | Alloskin rt, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4124 | Oasis ultra tri-layer wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4125 | Arthroflex, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4126 | Memoderm, dermaspan, tranzgraft or integuply, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4127 | Talymed, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4128 | Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |