Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list, page 77

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
S3620	Newborn metabolic screening panel, includes test kit, postage and the laboratory tests specified by the state for inclusion in this panel (e.g., galactose; hemoglobin, electro	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3630	Eosinophil count, blood direct	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3645	Hiv-1 Antibody Testing Of Or	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3650	Saliva Test, Hormone Level	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3652	Saliva Test, Hormone Level	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3655	Antisperm Antibodies Test (Immunobead)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3800	Genetic testing for amyotrophic lateral sclerosis (ALS)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3840	DNA analysis for germline mutations of the ret proto-oncogene	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3841	Genetic testing for retinoblastoma	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3842	Genetic testing for von hippel-lindau disease	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3844	DNA analysis of the connexin 26 gene (gjb2) for susceptibility to congenital, profound deafness	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3845	Genetic testing for alpha-thalassemia	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3846	Genetic testing for hemoglobin e beta-thalassemia	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3849	Genetic testing for niemann-pick disease	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3850	Genetic testing for sickle cell anemia	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3852	DNA analysis for apoe epilson 4 allele for susceptibility to Alzheimer's disease	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3853	Genetic testing for myotonic muscular dystrophy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3854	Gene expression profiling panel for use in the management of breast cancer treatment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3861	Genetic testing, sodium channel, voltage-gated, Type V, alpha subunit (SCN5A) and variants for suspected brugada syndrom	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3865	Comprehensive gene sequence analysis for hypertrophic cardiomyopathy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3866	Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mu	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3870	Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S3900	Surface electromyography (EMG)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S5181	Home Health Respiratory Therapy, NOS, Per Diem	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S8030	Scleral application of tantalum ring(s) for localization of lesions for proton beam therapy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S8037	Magnetic resonance cholangiopancreatography (MRCP)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S8130	Interferential current stimulator, 2 channel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S8131	Interferential current stimulator, 4 channel	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S8930	Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on- one contact with patient	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S8948	Application of a modality (requiring constant provider attendance) to one or	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S8950	Complex Lymphedema Therapy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S8990	Physical or manipulative therapy performed for maintenance rather than restoration	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9002	Intravaginal motion sensor system, provides biofeedback for pelvic floor muscle rehabilitation device	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9056	Coma Stimulation Per Diem	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9090	Vertebral Axial Decompressio	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9123	Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT cod	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9124	Nursing care, in the home; by licensed practical nurse, per hour	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9152	Speech therapy, re-evaluation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9336	Home infusion therapy, continuous anticoagulant infusion therapy (e.g., Heparin)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9351	Home infusion therapy, continuous or intermittent anti-emetic infusion therapy; administrative services, professional ph	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9364	Home infusion therapy, total parenteral nutrition (TPN) (do not use with home infusion codes S9365-S9368 using daily vol	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9365	Home infusion therapy, total parenteral nutrition (TPN); one liter per day	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9366	Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two liters per day	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9367	Home infusion therapy, total parenteral nutrition (TPN); more than two liter but no more than three liters per day	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9368	Home infusion therapy, total parenteral nutrition (TPN); more than three liter per day	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9373	Home infusion therapy, hydration therapy (do not use with hydration therapy codes S9374- S9377 using daily volume scales)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9374	Home infusion therapy, hydration therapy; one liter per day	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9375	Home infusion therapy, hydration therapy; more than one liter but no more than two liters per day	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9376	Home infusion therapy, hydration therapy; more than two liters but no more than three liters per day	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9377	Home infusion therapy, hydration therapy; more than three liters per day	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy

Sources

Disclaimer

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.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.