Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list, page 75

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

Prior authorization codes
Code	Description	Source
Q4344	Tri-membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4345	Matrix hd allograft dermis, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4346	Shelter dm matrix, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4347	Rampart dl matrix, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4348	Sentry sl matrix, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4349	Mantle dl matrix, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4350	Palisade dm matrix, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4351	Enclose tl matrix, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4352	Overlay sl matrix, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4353	Xceed tl matrix, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4354	Palingen dual-layer membrane and dual-layer palingen x-membrane, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4355	Abiomend xplus membrane and abiomend xplus hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4356	Abiomend membrane and abiomend hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4357	Xwrap plus, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4358	Xwrap dual, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4359	Choriply, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4360	Amchoplast fd, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4361	Epixpress, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4362	Cygnus disk, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4363	Amnio burgeon membrane and hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4364	Amnio burgeon xplus membrane and xplus hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4365	Amnio burgeon dual-layer membrane, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4366	Dual layer amnio burgeon x-membrane, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4367	Amniocore sl, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q4369	Amnioplast 3, per square centimeter (add-on, list separately in addition to primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5101	Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5103	Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5104	Injection, infliximab-abda, biosimilar, (renflexis), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5105	Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for ESRD on dialysis), 100 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5106	Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for non-ESRD use), 1000 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5107	Injection, bevacizumab-awwb, biosimilar, (Mvasi), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5108	Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5110	Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5111	Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5112	Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5113	Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5114	Injection, trastuzumab-dkst, biosimilar, (Ogivri), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5115	Injection, rituximab-abbs, biosimilar, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5116	Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5118	Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5119	Injection, rituximab-pvvr, biosimilar, (RUXIENCE), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5120	Injection, pegfilgrastim-bmez (ziextenzo), biosimilar, 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5121	Injection, infliximab-axxq, biosimilar, (AVSOLA), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 79 Original policy
Q5122	Injection, pegfilgrastim-apgf (nyvepria), biosimilar, 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5123	Injection, rituximab-arrx, biosimilar, (riabni), 10 m	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5125	Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5126	Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5127	Injection, pegfilgrastim-fpgk (stimufend), biosimilar, 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5129	Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5130	Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy

Sources

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The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

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