Anthem Blue Cross and Blue Shield Virginia prior authorization code reference, page 82

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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
0746T	Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiati	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0747T	Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0748T	Injections of stem cell product into perianal perifistular soft tissue, including fistula preparation (eg, removal of setons, fistula curettage, closure of internal openings)	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0766T	Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, with identification and marking of the treatment location, including noni	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0767T	Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, with identification and marking of the treatment location, including noni	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0770T	Virtual reality technology to assist therapy (List separately in addition to code for primary procedure)	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0771T	Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic servi	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0772T	Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic servi	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0773T	Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health ca	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0774T	Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health ca	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0778T	Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscl	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0787T	Revision or removal of neurostimulator electrode array, sacral, with integrated neurostimulator	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0795T	Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventric	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0796T	Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventric	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0797T	Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventric	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0800T	Transcatheter removal of permanent dual-chamber leadless pacemaker,?including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventricul	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0801T	Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging?guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0802T	Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging?guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0803T	Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging?guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0810T	Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0813T	Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of intragastric bariatric balloon	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0816T	Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (eg, array or leadless), and pulse generator or receiver, in	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0817T	Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (eg, array or leadless), and pulse generator or receiver, in	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0818T	Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subcut	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0819T	Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subfas	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0823T	Transcatheter insertion of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0824T	Transcatheter removal of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography an	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0825T	Transcatheter removal and replacement of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atria	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0864T	Low-intensity extracorporeal shock wave therapy involving corpus cavernosum, low energy	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0888T	Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including imaging guidance	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0894T	Cannulation of the liver allograft in preparation for connection to the normothermic perfusion device and decannulation of the liver allograft following normothermic perfusion	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0895T	Connection of liver allograft to normothermic machine perfusion device, hemostasis control; initial 4 hours of monitoring time, including hourly physiological and laboratory a	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0896T	Connection of liver allograft to normothermic machine perfusion device, hemostasis control; each additional hour, including physiological and laboratory assessments (eg, perfu	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0908T	Open implantation of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0909T	Replacement of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0910T	Removal of integrated neurostimulation system, vagus nerve	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0911T	Electronic analysis of implanted integrated neurostimulation system, vagus nerve; without programming by physician or other qualified health care professional	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0912T	Electronic analysis of implanted integrated neurostimulation system, vagus nerve; with simple programming by physician or other qualified health care professional	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0913T	Percutaneous transcatheter therapeutic drug delivery by intracoronary drugdelivery balloon (eg, drug-coated, drug-eluting), including mechanical dilation by nondrug-delivery	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0915T	Insertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and ther	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0923T	Removal and replacement of permanent cardiac contractility modulationdefibrillation pulse generator only	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0933T	Transcatheter implantation of wireless left atrial pressure sensor for long-term left atrial pressure monitoring, including sensor calibration and deployment, right heart cath	Virginia PPO standard precertification/prior authorization requirements, Pg 11 Original policy
0935T	Cystourethroscopy with renal pelvic sympathetic denervation, radiofrequency ablation, retrograde ureteral approach, including insertion of guide wire, selective placement of u	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
0951T	Totally implantable active middle ear hearing implant; initial placement, including mastoidectomy, placement of and attachment to sound processor	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
0952T	Totally implantable active middle ear hearing implant; revision or replacement, with mastoidectomy and replacement of sound processor	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
0953T	Totally implantable active middle ear hearing implant; revision or replacement, without mastoidectomy and replacement of sound processor	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
0954T	Totally implantable active middle ear hearing implant; replacement of sound processor only, with attachment to existing transducers	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
0955T	Totally implantable active middle ear hearing implant; removal, including removal of sound processor and all implant components	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
0966T	Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; dual arch, with additional mandibular advancement	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
0970T	Ablation, benign breast tumor (eg, fibroadenoma), percutaneous, laser, including imaging guidance when performed, each tumor	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy

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