Anthem Blue Cross and Blue Shield Virginia prior authorization, page 8

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
20936	Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
20937	Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
20938	Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separat	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
20939	Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
20974	Electrical Stimulation To Aid Bone Healing; Noninvasive (Nonoperative)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
20979	Low Intensity Ultrasound Stimulation To Aid Bone Healing; Noninvasive	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
20982	Ablation, Bone Tumor(s) Radiofrequency, Percutaneous, Including Computed Tomographic Guidance	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
20983	Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, includin	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21010	Arthrotomy, Temporomandibular Joint	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21050	Condylectomy, Temporomandibular Joint (Sep Proc)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21060	Meniscectomy, Partial/Complete, Temporomandibular Joint (Sep Proc)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21073	Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e., general or monitor	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21083	Impression & Custom Preparation; Palatal Lift Prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21086	Impression & Custom Preparation; Auricular Prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21087	Impression & Custom Preparation; Nasal Prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21110	Application, Interdental Fixation Device, Non-Fx/Dislocation, W/Removal	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21116	Injection Proc, Temporomandibular Joint Arthrography	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21120	Genioplasty; Augmentation (Autograft, Allograft, Prosthetic Matl)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21121	Genioplasty; Sliding Osteotomy, Single Piece	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21122	Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21123	Genioplasty; Sliding, Augmentation W/Interpositional Bone Grafts W/Obtaining Autograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21125	Augmentation, Mandibular Body/Angle; Prosthetic Matl	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21127	Augmentation, Mandibular Body/Angle; W/Bone Graft/Onlay/Interpositional W/Obtaining Autograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21137	Reduction Forehead; Contouring Only	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21138	Reduction Forehead; Contouring/Prosthesis/Bone Graft W/Obtaining Autograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21139	Reduction Forehead; Contouring & Setback, Anterior Frontal Sinus Wall	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21141	Reconstruction Midface, Lefort I; 1 Piece, W/O Bone Graft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21142	Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21143	Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21145	Reconstruction Midface, Lefort I; 1 Piece, W/Bone Grafts	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21146	Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21147	Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes o	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21150	Reconstruction Midface, Lefort Ii; Anterior Intrusion	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21151	Reconstruction Midface, Lefort Ii; W/Bone Grafts	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21154	Reconstruction Midface, Lefort Iii, W/Bone Grafts; W/O Lefort I	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 12 Original policy
21155	Reconstruction Midface, Lefort Iii, W/Bone Grafts; W/Lefort I	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21159	Reconstruction Midface, Lefort Iii, (Extra/Intracranial), W/Bone Grafts, W/O Lefort I	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21160	Reconstruction Midface, Lefort Iii, (Extra/Intracranial), W/Bone Grafts, W/Lefort I	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21172	Reconstruction Superior-Lateral Orbital Rim & Lower Forehead	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21175	Reconstruction, Bifrontal,Superior-Lateral Orbital Rims & Lower Forehead	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21179	Reconstruction, Majority, Forehead & Supraorbital Rims; W/Grafts (Allograft/Prosthetic)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21180	Reconstruction, Majority, Forehead & Supraorbital Rims; W/Autograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21182	Reconstruction, Orbit/Forehead/Nasoethmoid, Following Excision, Benign Tumor, Graft < 40 Sq Cm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21183	Reconstruction, Orbit/Forehead/Nasoethmiod, Following Excision, Benign Tumor, Graft 40-80 Sq Cm	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21188	Reconstruction, Midface, Osteotomies (Non-Lefort Type), W/Grafts, W/Obtaining Autografts	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21193	Reconstruction, Mandibular Rami, Horizontal, Vertical, "C"/"L" Osteotomy; W/O Bone Graft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21194	Reconstruction, Mandibular Rami, Horizontal, Vertical, "C"/"L" Osteotomy; W/Bone Graft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21195	Reconstruction, Mandibular Rami &/Or Body, Sagittal Split; W/O Int Rigid Fixation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21196	Reconstruction, Mandibular Rami &/Or Body, Sagittal Split; W/Int Rigid Fixation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21198	Osteotomy, Mandible, Segmental	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 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.

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