Anthem Blue Cross and Blue Shield Virginia prior authorization code reference, page 81

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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

Imported source codes and labels; verify the complete review requirements in the original document
Code	Description	Source
0581T	Ablation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging guidance when performed, unilateral	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0584T	Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when perf	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0585T	Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when perf	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0586T	Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when perf	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0596T	Temporary female intraurethral valve-pump (ie, voiding prosthesis); initial insertion, including urethral measurement	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0597T	Temporary female intraurethral valve-pump (ie, voiding prosthesis); replacement	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0600T	Ablation, irreversible electroporation; 1 or more tumors per organ, other than liver or prostate, including imaging guidance, when performed, percutaneous	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0601T	Ablation, irreversible electroporation; 1 or more tumors per organ, including fluoroscopic and ultrasound guidance, when performed, open	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0607T	Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0608T	Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0614T	Removal and replacement of substernal implantable defibrillator pulse generator	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0615T	Automated analysis of binocular eye movements without spatial calibration, including disconjugacy, saccades, and pupillary dynamics for the assessment of concussion, with inte	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0620T	Endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0627T	Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first le	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0629T	Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0633T	Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast material	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0634T	Computed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s)	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0635T	Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s)	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0636T	Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s)	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0637T	Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s)	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0638T	Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s)	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0646T	Transcatheter tricuspid valve implantation/replacement (TTVI) with pro	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0648T	Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmissio	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0652T	Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, includin	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0653T	Esophagogastroduodenoscopy, flexible, transnasal; with biopsy, single	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0654T	Esophagogastroduodenoscopy, flexible, transnasal; with insertion of in	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0655T	Transperineal focal laser ablation of malignant prostate tissue, inclu	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0658T	Electrical impedance spectroscopy of 1 or more skin lesions for automa	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0659T	Transcatheter intracoronary infusion of supersaturated oxygen in conju	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0664T	Donor hysterectomy (including cold preservation); open, from cadaver d	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0665T	Donor hysterectomy (including cold preservation); open, from living do	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0666T	Donor hysterectomy (including cold preservation); laparoscopic or robo	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0667T	Donor hysterectomy (including cold preservation); recipient uterus all	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0668T	Backbench standard preparation of cadaver or living donor uterine allo	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0669T	Backbench reconstruction of cadaver or living donor uterus allograft p	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0670T	Backbench reconstruction of cadaver or living donor uterus allograft p	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0671T	Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0672T	Endovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0673T	Ablation, benign thyroid nodule(s), percutaneous, laser, including imaging guidance	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0686T	Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0689T	Quantitative ultrasound tissue characterization (non-elastographic), including interpretation and report, obtained without diagnostic ultrasound examination of the same anatom	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0692T	Therapeutic ultrafiltration	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0700T	Molecular fluorescent imaging of suspicious nevus; first lesion	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0701T	Molecular fluorescent imaging of suspicious nevus; each additional lesion (List separately in addition to code for primary procedure)	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0707T	Injection(s), bone-substitute material (eg, calcium phosphate) into subchondral bone defect (ie, bone marrow lesion, bone bruise, stress injury, microtrabecular fracture), inc	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0714T	Transperineal laser ablation of benign prostatic hyperplasia, including imaging guidance; prostate volume less than 50 mL	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0717T	Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, i	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0718T	Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilate	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0736T	Colonic lavage, 35 or more liters of water, gravity-fed, with induced defecation, including insertion of rectal catheter	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy
0745T	Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image da	Virginia PPO standard precertification/prior authorization requirements, Pg 10 Original policy

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