Anthem Blue Cross and Blue Shield Virginia prior authorization, page 71
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 |
|---|---|---|
| Q4130 | Strattice tm, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4132 | Grafix core and grafixpl core, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4133 | Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4134 | Hmatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4135 | Mediskin, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4137 | Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4138 | Biodfence dryflex, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4139 | Amniomatrix or biodmatrix, injectable, 1 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4140 | Biodfence, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4141 | Alloskin ac, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4142 | Xcm biologic tissue 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 |
| Q4143 | Repriza, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4145 | Epifix, injectable, 1 mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4146 | Tensix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4147 | Architect, architect px, or architect fx, extracellular 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 |
| Q4148 | Neox cord 1k, neox cord rt, or clarix cord 1k, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4149 | Excellagen, 0.1 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4150 | Allowrap ds or dry, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4151 | Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy |
| Q4152 | Dermapure, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4153 | Dermavest and plurivest, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4154 | Biovance, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4155 | Neoxflo or clarixflo, 1 mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4156 | Neox 100 or clarix 100, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4157 | Revitalon, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4158 | Kerecis omega3, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4159 | Affinity, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4160 | Nushield, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4161 | Bio-connekt wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4162 | WoundEx Flow, BioSkin Flow, 0.5 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4163 | Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4164 | Helicoll, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4165 | Keramatrix or kerasorb, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4166 | Cytal, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4167 | Truskin, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4169 | Artacent wound, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4170 | Cygnus, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4171 | Interfyl, 1 mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4173 | Palingen or palingen xplus, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4174 | Palingen or promatrx, 0.36 mg per 0.25 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4175 | Miroderm, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4176 | Neopatch or therion, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4177 | FlowerAmnioFlo, 0.1 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4178 | Floweramniopatch, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4179 | Flowerderm, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4180 | Revita, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4181 | Amnio wound, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4183 | Surgigraft, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4184 | Cellesta or cellesta duo, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4185 | Cellesta Flowable Amnion (25 mg per cc); per 0.5 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |