Anthem Blue Cross and Blue Shield Virginia prior authorization code reference, page 79
Source code lookup
Each row links an imported source code to its service or category label. Check the original document for the complete plan scope, review type and qualifications.
Source code index
| Code | Description | Source |
|---|---|---|
| 0449U | Carrier screening for severe inherited conditions (eg, cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia), r | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0452U | Oncology (bladder), methylated PENK DNA detection by linear target enrichment-quantitative methylation-specific real-time PCR (LTE-qMSP), urine, reported as likelihood of blad | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0453U | Oncology (colorectal cancer), cell-free DNA (cfDNA), methylation-based quantitative PCR assay (SEPTIN9, IKZF1, BCAT1, Septin9-2, VAV3, BCAN), plasma, reported as presence or a | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0454U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0457U | Perfluoroalkyl substances (PFAS) (eg, perfluorooctanoic acid, perfluorooctane sulfonic acid), 9 PFAS compounds by LC-MS/MS, plasma or serum, quantitative | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0460U | Oncology, whole blood or buccal, DNA single-nucleotide polymorphism (SNP) genotyping by real-time PCR of 24 genes, with variant analysis and reported phenotypes | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0461U | Oncology, pharmacogenomic analysis of single-nucleotide polymorphism (SNP) genotyping by real-time PCR of 24 genes, whole blood or buccal swab, with variant analysis, includin | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0465U | Oncology (urothelial carcinoma), DNA, quantitative methylation-specific PCR of 2 genes (ONECUT2, VIM), algorithmic analysis reported as positive or negative | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0466U | Cardiology (coronary artery disease [CAD]), DNA, genome-wide association studies (564856 single-nucleotide polymorphisms [SNPs], targeted variant genotyping), patient lifestyl | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0467U | Oncology (bladder), DNA, next-generation sequencing (NGS) of 60 genes and whole genome aneuploidy, urine, algorithms reported as minimal residual disease (MRD) status positive | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0469U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis for chromosomal abnormalities, copy number variants, duplications/deletions, inversions, unb | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0471U | Oncology (colorectal cancer), qualitative real-time PCR of 35 variants of KRAS and NRAS genes (exons 2, 3, 4), formalin-fixed paraffin-embedded (FFPE), predictive, identificat | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0472T | Device evaluation, interrogation, and initial programming of intra- ocular retinal electrode array (eg, retinal prosthesis), in person, with iterative adjustment of the implan | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0473T | Device evaluation and interrogation of intra-ocular retinal electrode array (eg, retinal prosthesis), in person, including reprogramming and visual training, when performed, w | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0473U | Oncology (solid tumor), next-generation sequencing (NGS) of DNA from formalin-fixed paraffin-embedded (FFPE) tissue with comparative sequence analysis from a matched normal sp | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0474T | Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0474U | Hereditary pan-cancer (eg, hereditary sarcomas, hereditary endocrine tumors, hereditary neuroendocrine tumors, hereditary cutaneous melanoma), genomic sequence analysis panel | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0475U | Hereditary prostate cancer-related disorders, genomic sequence analysis panel using next- generation sequencing (NGS), Sanger sequencing, multiplex ligation-dependent probe amp | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0476U | Drug metabolism, psychiatry (eg, major depressive disorder, general anxiety disorder, attention deficit hyperactivity disorder [ADHD], schizophrenia), whole blood, buccal swab | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0477U | Drug metabolism, psychiatry (eg, major depressive disorder, general anxiety disorder, attention deficit hyperactivity disorder [ADHD], schizophrenia), whole blood, buccal swab | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0478U | Oncology (non-small cell lung cancer), DNA and RNA, digital PCR analysis of 9 genes (EGFR, KRAS, BRAF, ALK, ROS1, RET, NTRK 1/2/3, ERBB2, and MET) in formalin-fixed paraffin-e | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0480U | Infectious disease (bacteria, viruses, fungi, and parasites), cerebrospinal fluid (CSF), metagenomic next-generation sequencing (DNA and RNA), bioinformatic analysis, with pos | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0481T | Injection(s), autologous white blood cell concentrate (autologous protein solution), any site, including image guidance, harvesting and preparation, when performed | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0482U | Obstetrics (preeclampsia), biochemical assay of soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF), serum, ratio reported for sFlt-1/PlGF, with ris | Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy |
| 0483T | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0484T | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (eg, thoracotomy, transapical) | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0485U | Oncology (solid tumor), cell-free DNA and RNA by next-generation sequencing, interpretative report for germline mutations, clonal hematopoiesis of indeterminate potential, and | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0486U | Oncology (pan-solid tumor), next-generation sequencing analysis of tumor methylation markers present in cell-free circulating tumor DNA, algorithm reported as quantitative mea | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0487U | Oncology (solid tumor), cell-free circulating DNA, targeted genomic sequence analysis panel of 84 genes, interrogation for sequence variants, aneuploidy-corrected gene copy nu | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0488U | Obstetrics (fetal antigen noninvasive prenatal test), cell-free DNA sequence analysis for detection of fetal presence or absence of 1 or more of the Rh, C, c, D, E, Duffy (Fya | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0489T | Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0489U | Obstetrics (single-gene noninvasive prenatal test), cell-free DNA sequence analysis of 1 or more targets (eg, CFTR, SMN1, HBB, HBA1, HBA2) to identify paternally inherited pat | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0490T | Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0493U | Transplantation medicine, quantification of donor-derived cell-free DNA (cfDNA) using next- generation sequencing, plasma, reported as percentage of donor-derived cell-free DNA | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0494T | Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system, including decannulation, separation from the perfusion sys | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0494U | Red blood cell antigen (fetal RhD gene analysis), next-generation sequencing of circulating cell- free DNA (cfDNA) of blood in pregnant individuals known to be RhD negative, re | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0495T | Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and labo | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0496U | Oncology (colorectal), cell-free DNA, 8 genes for mutations, 7 genes for methylation by real- time RT-PCR, and 4 proteins by enzyme-linked immunosorbent assay, blood, reported | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0497U | Oncology (prostate), mRNA gene-expression profiling by real-time RT-PCR of 6 genes (FOXM1, MCM3, MTUS1, TTC21B, ALAS1, and PPP2CA), utilizing formalin-fixed paraffin-embedded | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0498U | Oncology (colorectal), next-generation sequencing for mutation detection in 43 genes and methylation pattern in 45 genes, blood, and formalin-fixed paraffin-embedded (FFPE) ti | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0499U | Oncology (colorectal and lung), DNA from formalin-fixed paraffin-embedded (FFPE) tissue, next-generation sequencing of 8 genes (NRAS, EGFR, CTNNB1, PIK3CA, APC, BRAF, KRAS, an | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0500U | Autoinflammatory disease (VEXAS syndrome), DNA, UBA1 gene mutations, targeted variant analysis (M41T, M41V, M41L, c.118-2A>C, c.118-1G>C, c.118-9_118-2del, S56F, S621C) | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0503U | Neurology (Alzheimer disease), beta amyloid (AB40, AB42, AB42/40 ratio) and tau-protein (ptau217, np-tau217, ptau217/np-tau217 ratio), blood, immunoprecipitation with quantita | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0505T | Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0506U | Gastroenterology (Barrett's esophagus), esophageal cells, DNA methylation analysis by next- generation sequencing of at least 89 differentially methylated genomic regions, algo | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0507U | Oncology (ovarian), DNA, whole-genome sequencing with 5-hydroxymethylcytosine (5hmC) enrichment, using whole blood or plasma, algorithm reported as cancer detected or not dete | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0510T | Removal of sinus tarsi implant | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0511T | Removal and reinsertion of sinus tarsi implant | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0512T | Extracorporeal shock wave for integumentary wound healing, including topical application and dressing care; initial wound | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |
| 0515T | Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performe | Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy |