Anthem Blue Cross and Blue Shield Virginia prior authorization, page 72
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 |
|---|---|---|
| Q4186 | Epifix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4187 | Epicord, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4188 | Amnioarmor, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4189 | Artacent AC, 1 mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4190 | Artacent ac, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4191 | Restorigin, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4192 | Restorigin, 1 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4193 | Coll-e-derm, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4194 | Novachor, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4195 | Puraply, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4196 | Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4197 | Puraply xt, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4198 | Genesis amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4199 | Cygnus 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 |
| Q4200 | Skin te, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4201 | Matrion, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4202 | Keroxx (2.5g/cc), 1cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4203 | Derma-gide, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4204 | Xwrap, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4205 | Membrane graft or membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4206 | Fluid flow or fluid GF, 1 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4208 | Novafix, per square cenitmeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4209 | Surgraft, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4211 | Amnion bio or axobiomembrane, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4212 | Allogen, per cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 76 Original policy |
| Q4213 | Ascent, 0.5 mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4214 | Cellesta cord, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4215 | Axolotl ambient or axolotl cryo, 0.1 mg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4216 | Artacent cord, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4217 | Woundfix, biowound, woundfix plus, biowound plus, woundfix xplus or biowound xplus, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4218 | Surgicord, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4219 | Surgigraft-dual, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4220 | Bellacell hd or surederm, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4221 | Amniowrap2, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4222 | Progenamatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4224 | Human health factor 10 amniotic patch (hhf10-p), per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4225 | Amniobind or dermabind tl, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4226 | MyOwn skin, includes harvesting and preparation procedures, per square centimeter | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4227 | Amniocore, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4229 | Cogenex amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4230 | Cogenex Flowable Amnion, per 0.5 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4232 | Corplex, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4233 | SurFactor or NuDyn, per 0.5 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4234 | Xcellerate, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4235 | Amniorepair or altiply, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4236 | Carepatch, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4237 | Cryo-cord, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4238 | Derm-maxx, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4239 | Amnio-maxx or amnio-maxx lite, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4240 | CoreCyte, for topical use only, per 0.5 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |