Anthem Blue Cross and Blue Shield Virginia prior authorization code reference, page 86

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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
33227	Removal Of Permanent Pacemaker Pulse Generator With Replacement Of Pacemaker Pulse Generator; Single Lead System	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33228	Removal Of Permanent Pacemaker Pulse Generator With Replacement Of Pacemaker Pulse Generator; Dual Lead System	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33229	Removal Of Permanent Pacemaker Pulse Generator With Replacement Of Pacemaker Pulse Generator; Multiple Lead System	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33230	Insertion Of Pacing Cardioverter-Defibrillator Pulse Generator Only; With Existing Dual Leads	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33231	Insertion Of Pacing Cardioverter-Defibrillator Pulse Generator Only; With Existing Multiple Leads	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33233	Removal of permanent pacemaker pulse generator only	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33234	Removal, Transvenous Pacemaker Electrode(S); Single Lead System, Atrial/Ventricular	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33235	Removal, Transvenous Pacemaker Electrode(S); Dual Lead System	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33240	Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33249	Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33263	Removal Of Pacing Cardioverter-Defibrillator Pulse Generator With Replacement Of Pacing Cardioverter-Defibrillator Pulse Generator; Dual Lead System	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33264	Removal Of Pacing Cardioverter-Defibrillator Pulse Generator With Replacement Of Pacing Cardioverter-Defibrillator Pulse Generator; Multiple Lead System	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33270	Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of a	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33271	Insertion of subcutaneous implantable defibrillator electrode	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33274	Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, fe	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33275	Transcatheter removal of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography)	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33276	Insertion of phrenic nerve stimulator system (pulse generator and stimulating lead[s]), including vessel catheterization, all imaging guidance, and pulse generator initial ana	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33277	Insertion of phrenic nerve stimulator transvenous sensing lead (List separately in addition to code for primary procedure)	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33278	Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; system, including pulse generat	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33279	Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sens	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33280	Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator only	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33281	Repositioning of phrenic nerve stimulator transvenous lead(s)	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33285	Insertion, subcutaneous cardiac rhythm monitor, including programming	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33287	Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33288	Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous sti	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33289	Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart c	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33418	Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis	Virginia PPO standard precertification/prior authorization requirements, Pg 22 Original policy
33477	Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33927	Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33928	Removal and replacement of total replacement heart system (artificial heart)	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33930	Donor Cardiectomy-Pneumonectomy, W/Preparation & Maintenance, Allograft	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33933	Backbench Standard Preparation Of Cadaver Donor Heart/Lung Allograft	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33935	Heart-Lung Transplant W/Recipient Cardiectomy-Pneumonectomy	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33940	Donor Cardiectomy, W/Preparation & Maintenance, Allograft	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33944	Backbench Standard Preparation Of Cadaver Donor Heart Allograft	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33945	Heart Transplant, W/Wo Recipient Cardiectomy	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33975	Insertion, Ventricular Assist Device; Extracorporeal, Single Ventricle	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33976	Insertion, Ventricular Assist Device; Extracorporeal, Biventricular	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33979	Insertion, Ventricular Assist Device, Implantable Intracorporeal, Single Ventricle	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33981	Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33982	Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33983	Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary byp	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33990	Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, arterial access only	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33991	Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, both arterial and venous access, with transseptal punc	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33993	Repositioning of percutaneous right or left heart ventricular assist device with imaging guidance at separate and distinct session from insertion	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
33995	Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right heart, venous access only	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
36260	Insertion, Implantable Intra-Arterial Infusion Pump	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
36261	Revision, Implanted Intra-Arterial Infusion Pump	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
36465	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; singl	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy
36466	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multi	Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy

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