Anthem Blue Cross and Blue Shield Virginia prior authorization code reference, page 88

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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
38207	Transplant Preparation, Hematopoietic Progenitor Cells; Cryopreservation & Storage	Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy
38208	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor	Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy
38209	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor	Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy
38210	Transplant Prep, Hematopoietic Progenitor Cells; Specfc Cell Deplet W/In Harvest, T-Cell Deplete	Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy
38211	Transplant Preparation, Hematopoietic Progenitor Cells; Tumor Cell Deplete	Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy
38212	Transplant Preparation, Hematopoietic Progenitor Cells; Red Blood Cell Removal	Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy
38213	Transplant Preparation, Hematopoietic Progenitor Cells; Platelet Depletion	Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy
38214	Transplant Preparation, Hematopoietic Progenitor Cells; Plasma (Volume) Depletion	Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy
38215	Transplant Prep, Hematoiepotic Progenitor Cells; Cell Conc, Plasma/Mononuclear/Buffy Coat	Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy
38230	Bone marrow harvesting for transplantation; allogeneic	Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy
38232	Bone Marrow Harvesting For Transplantation; Autologous	Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy
38240	Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
38241	Hematopoietic progenitor cell (HPC); autologous transplantation	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
38243	Hematopoietic progenitor cell (HPC); HPC boost	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
41019	Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transn	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
41512	Tongue base suspension, permanent suture technique	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
41530	Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
42145	Palatopharyngoplasty	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43229	Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43233	Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43235	Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43239	Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43241	Esophagogastroduodenoscopy, flexible, transoral; with insertion of intraluminal tube or catheter	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43243	Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric varices	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43244	Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43245	Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie)	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43246	Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43247	Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43248	Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43249	Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43250	Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43251	Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43254	Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43255	Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43266	Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43270	Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performe	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43281	Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of me	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
43282	Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh	Virginia PPO standard precertification/prior authorization requirements, Pg 25 Original policy
57265	Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed; with enterocele repair	Virginia PPO standard precertification/prior authorization requirements, Pg 28 Original policy
57270	Repair, Enterocele, Abdominal Approach (Sep Proc)	Virginia PPO standard precertification/prior authorization requirements, Pg 28 Original policy
57280	Colpopexy, Abdominal Approach	Virginia PPO standard precertification/prior authorization requirements, Pg 28 Original policy
57283	Colpopexy, Vaginal; Intra-Peritoneal Approach (Uterosacral, Levator Myorrhaphy)	Virginia PPO standard precertification/prior authorization requirements, Pg 28 Original policy
57284	Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach	Virginia PPO standard precertification/prior authorization requirements, Pg 28 Original policy
57285	Paravaginal defect repair (including repair of cystocele, if performed) ;vaginal approach	Virginia PPO standard precertification/prior authorization requirements, Pg 28 Original policy
57423	Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach	Virginia PPO standard precertification/prior authorization requirements, Pg 29 Original policy
82787	Gammaglobulin (immunoglobulin); immunoglobulin subclasses (eg, IgG1, 2, 3, or 4), each	Virginia PPO standard precertification/prior authorization requirements, Pg 41 Original policy
83516	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitativ	Virginia PPO standard precertification/prior authorization requirements, Pg 41 Original policy
83520	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise sp	Virginia PPO standard precertification/prior authorization requirements, Pg 41 Original policy
83695	Lipoprotein (a)	Virginia PPO standard precertification/prior authorization requirements, Pg 41 Original policy
83698	Lipoprotein-associated phospholipase A2, (Lp-PLA2)	Virginia PPO standard precertification/prior authorization requirements, Pg 41 Original policy

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