Anthem Blue Cross and Blue Shield Virginia prior authorization, page 9

CPT code lookup

Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.

Prior authorization codes

Prior authorization codes
Code	Description	Source
21199	Osteotomy, Mandible, Segmental; W/Genioglossus Advancement	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21206	Osteotomy, Maxilla, Segmental	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21208	Osteoplasty, Facial Bones; Augmentation (Autograft, Allograft/Prosthetic Implant)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21209	Osteoplasty, Facial Bones; Reduction	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21210	Graft, Bone; Nasal, Maxillary/Malar Areas (Includes Obtaining Graft)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21215	Graft, Bone; Mandible (Includes Obtaining Graft)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21230	Graft; Rib Cartilage, Autogenous, Face/Chin/Nose/Ear (Includes Obtaining Graft)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21235	Graft; Ear Cartilage, Autogenous, Nose/Ear (Includes Obtaining Graft)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21240	Arthroplasty, Temporomandibular Joint, W/Wo Autograft (Includes Obtaining Graft)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21242	Arthroplasty, Temporomandibular Joint, W/Allograft	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21243	Arthroplasty, Temporomandibular Joint, W/Prosthetic Joint Replacement	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21244	Reconstruction, Mandible, Extraoral, W/Transosteal Bone Plate	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21245	Reconstruction, Mandible/Maxilla, Subperiosteal Implant; Partial	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21246	Reconstruction, Mandible/Maxilla, Subperiosteal Implant; Complete	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21247	Reconstruction, Mandibular Condyle W/Bone & Cartilage Autografts	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21255	Reconstruction, Zygomatic Arch/Glenoid Fossa W/Bone & Cartilage (Includes Obtaining Autografts)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21256	Reconstruction, Orbit W/Osteotomies & Bone Grafts (Includes Obtaining Autografts)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21270	Malar Augmentation, Prosthetic Matl	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21275	Secondary Revision, Orbitocraniofacial Reconstruction	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21685	Hyoid Myotomy and Suspension	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21740	Reconstructive Repair, Pectus Excavatum/Carinatum; Open	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21742	Reconstructive Repair, Pectus Excavatum/Carinatum; Minimal Invasive Approach, W/O Thoracoscopy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21743	Reconstructive Repair, Pectus Excavatum/Carinatum; Minimal Invasive Approach, W/Thoracoscopy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21811	Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
21812	Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22206	Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral bo	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22207	Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral bo	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22208	Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral bo	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22210	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22212	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22214	Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22216	Osteotomy, Spine, Posterior/Posterolateral Approach, 1 Vertebral Segment; Add'l Segment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22220	Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22222	Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22224	Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22226	Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary proce	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22505	Manipulation, Spine, Requiring Anesthesia, Any Region	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22510	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22511	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22512	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cerv	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22513	Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 verteb	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 13 Original policy
22514	Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 verteb	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy
22515	Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 verteb	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy
22526	Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single le	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy
22527	Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral, including fluoroscopic guidance; 1 or mor	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy
22532	Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy
22533	Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy
22534	Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy
22551	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy
22552	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each add	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 14 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.