Anthem Blue Cross and Blue Shield Virginia prior authorization, page 73
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 |
|---|---|---|
| Q4241 | PolyCyte, for topical use only, per 0.5 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4242 | AmnioCyte Plus, per 0.5 cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4245 | AmnioText, per cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4246 | CoreText or ProText, per cc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4247 | Amniotext patch, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4248 | Dermacyte amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4249 | Amniply, for topical use only, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4250 | Amnioamp-mp, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4251 | Vim, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4252 | Vendaje, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4253 | Zenith 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 |
| Q4254 | Novafix dl, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4255 | Reguard, for topical use only, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4256 | Mlg-complete, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4257 | Relese, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4258 | Enverse, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4259 | Celera dual layer or celera dual 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 |
| Q4260 | Signature apatch, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4261 | Tag, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4262 | Dual layer impax 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 |
| Q4263 | Surgraft 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 |
| Q4264 | Cocoon 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 |
| Q4265 | Neostim 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 |
| Q4266 | Neostim 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 |
| Q4267 | Neostim dl, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4268 | Surgraft ft, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4269 | Surgraft xt, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4270 | Complete sl, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4271 | Complete ft, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4272 | Esano a, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4273 | Esano aaa, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 77 Original policy |
| Q4274 | Esano ac, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4275 | Esano aca, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4276 | Orion, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4278 | Epieffect, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4279 | Vendaje ac, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4280 | Xcell amnio matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4281 | Barrera sl or barrera dl, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4282 | Cygnus dual, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4283 | Biovance tri-layer or biovance 3l, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4284 | Dermabind sl, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4285 | Nudyn dl or nudyn dl mesh, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4286 | Nudyn sl or nudyn slw, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4287 | Dermabind dl, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4288 | Dermabind ch, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4289 | Revoshield + amniotic barrier, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4290 | Membrane wrap-hydro, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4291 | Lamellas xt, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4292 | Lamellas, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |
| Q4293 | Acesso dl, per square centimeter (add-on, list separately in addition to primary procedure) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 78 Original policy |