Anthem Blue Cross and Blue Shield Virginia prior authorization code reference, page 85

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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

Imported source codes and labels; verify the complete review requirements in the original document
Code	Description	Source
30430	Rhinoplasty, Secondary; Minor Revision (Small Amount, Nasal Tip Work)	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
30435	Rhinoplasty, Secondary; Intermediate Revision (Bony Work W/Osteotomies)	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
30450	Rhinoplasty, Secondary; Major Revision (Nasal Tip Work & Osteotomies)	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
30468	Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s)	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
30469	Repair of nasal valve collapse with low energy, temperature-controlled (ie, radiofrequency) subcutaneous/submucosal	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
30520	Septoplasty/Submucous Resection W/Wo Cartilage Scoring/Contouring/Graft	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
30620	Septal/Other Intranasal Dermatoplasty (Does Not Include Obtaining Graft)	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31237	Nasal/Sinus Endoscopy, Surgical; W/Bx, Polypectomy/Debridement (Sep Proc)	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31242	Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation, posterior nasal nerve	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31243	Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31253	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when perfor	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31254	Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31255	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31256	Nasal/Sinus Endoscopy, Surgical, W/Maxillary Antrostomy	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31257	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31259	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31267	Nasal/Sinus Endoscopy, Surgical, W/Maxillary Antrostomy; W/Maxillary Tissue Removal	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31276	Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31287	Nasal/Sinus Endoscopy, Surgical, W/Sphenoidotomy	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31288	Nasal/Sinus Endoscopy, Surgical, W/Sphenoidotomy; W/Tissue Removal, Sphenoid Sinus	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31295	Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31296	Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31297	Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); sphenoid sinus ostium	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31298	Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31660	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
31661	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
32701	Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
32850	Donor pneumonectomy(s) (including cold preservation), from cadaver donor	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
32851	Lung Transplant, Single; W/O Cardiopulmonary Bypass	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
32852	Lung Transplant, Single; W/Cardiopulmonary Bypass	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
32853	Lung Transplant, Double (Bilat Sequential/En Bloc); W/O Cardiopulmonary Bypass	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
32854	Lung Transplant, Double (Bilat Sequential/En Bloc); W/Cardiopulmonary Bypass	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
32855	Backbench Standard Preparation Of Cadaver Donor Lung Allograft; Unilateral	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
32856	Backbench Standard Preparation Of Cadaver Donor Lung Allograft; Bilateral	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
32994	Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
32998	Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33206	Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33207	Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33208	Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33212	Insertion of pacemaker pulse generator only; with existing single lead	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33213	Insertion of pacemaker pulse generator only; with existing dual leads	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33214	Repositioning, Previously Implanted Transvenous Electrode/Pacing Cardiovert-Defib Electrode	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33215	Repositioning of Previously Implanted Transvenous Pacemaker or Pacing Cardioverter- Defibrillator Electrode	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33216	Insertion of a single transvenous electrode, permanent pacemaker or cardioverter-defibrillator	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33217	Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverter-defibrillator	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33218	Repair of single transvenous electrode, permanent pacemaker or pacing cardioverter- defibrillator	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33220	Repair of 2 transvenous electrodes for permanent pacemaker or pacing cardioverter- defibrillator	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33222	Relocation of skin pocket for pacemaker	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33224	Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse ge	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33226	Repositioning Of Previously Implanted Cardiac Venous System (Left Ventricular) Electrode (Including Removal, Insertion And/Or Replacement Of Existing Generator)	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy

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