Anthem Blue Cross and Blue Shield Virginia policy
Bundled Services and Supplies - Professional
Bundled Services and Supplies - Professional is a public Anthem Blue Cross and Blue Shield Virginia policy (policy C-08003, effective Dec 1, 2025). It lists 341 CPT or HCPCS codes, 58 of them on the Anthem Blue Cross and Blue Shield Virginia prior authorization list. Not a coverage decision; the payer's own document governs.
View the original policy (PDF) ↗
- Policy number
- C-08003
- Effective
- Dec 1, 2025
- Line of business
- Commercial
- States
- VA
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross and Blue Shield Virginia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield Virginia policies |
|---|---|---|---|
| 08002 | Not listed | Policies naming 08002 | |
| 08003 | Not listed | Policies naming 08003 | |
| 08011 | Not listed | Policies naming 08011 | |
| 09001 | Not listed | Policies naming 09001 | |
| 09006 | Not listed | Policies naming 09006 | |
| 0902T | Not listed | Policies naming 0902T | |
| 0903T | Not listed | Policies naming 0903T | |
| 0904T | Not listed | Policies naming 0904T | |
| 0905T | Not listed | Policies naming 0905T | |
| 0945T | Not listed | Policies naming 0945T | |
| 13005 | Not listed | Policies naming 13005 | |
| 19081 | Not listed | Policies naming 19081 | |
| 19101 | Not listed | Policies naming 19101 | |
| 19281 | Not listed | Policies naming 19281 | |
| 19288 | Not listed | Policies naming 19288 | |
| 20550 | Not listed | Policies naming 20550 | |
| 20551 | Not listed | Policies naming 20551 | |
| 20552 | Not listed | Policies naming 20552 | |
| 20553 | Not listed | Policies naming 20553 | |
| 22558 | On the list | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | Policies naming 22558 |
| 22600 | On the list | Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment | Policies naming 22600 |
| 22610 | On the list | Arthrodesis, posterior or posterolateral technique, single interspace; thoracic (with lateral transverse technique, when performed) | Policies naming 22610 |
| 22612 | On the list | Arthrodesis, posterior or posterolateral technique, single interspace; lumbar (with lateral transverse technique, when performed) | Policies naming 22612 |
| 22614 | On the list | Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (List separately in addition to code for primary procedure) | Policies naming 22614 |
| 22630 | On the list | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar | Policies naming 22630 |
| 22633 | On the list | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other | Policies naming 22633 |
| 24002 | Not listed | Policies naming 24002 | |
| 24004 | Not listed | Policies naming 24004 | |
| 29806 | On the list | Arthroscopy, shoulder, surgical; capsulorrhaphy | Policies naming 29806 |
| 29807 | On the list | Arthroscopy, shoulder, surgical; repair of SLAP lesion | Policies naming 29807 |
| 29819 | On the list | Arthroscopy, shoulder, surgical; with removal of loose body or foreign body | Policies naming 29819 |
| 29820 | On the list | Arthroscopy, shoulder, surgical; synovectomy, partial | Policies naming 29820 |
| 29821 | On the list | Arthroscopy, shoulder, surgical; synovectomy, complete | Policies naming 29821 |
| 29822 | On the list | Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, bi | Policies naming 29822 |
| 29823 | On the list | Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilag | Policies naming 29823 |
| 29824 | On the list | Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) | Policies naming 29824 |
| 29825 | On the list | Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation | Policies naming 29825 |
| 29827 | On the list | Arthroscopy, shoulder, surgical; with rotator cuff repair | Policies naming 29827 |
| 29834 | Not listed | Policies naming 29834 | |
| 29835 | Not listed | Policies naming 29835 | |
| 29836 | Not listed | Policies naming 29836 | |
| 29837 | Not listed | Policies naming 29837 | |
| 29838 | Not listed | Policies naming 29838 | |
| 29876 | On the list | Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) | Policies naming 29876 |
| 29879 | On the list | Arthroscopy, Knee, Surgical; Abrasion Arthroplasty (W/Chondroplasty)/Multiple Drilling/Microfx | Policies naming 29879 |
| 29880 | On the list | Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same | Policies naming 29880 |
| 29887 | On the list | Arthroscopy, Knee, Surgical; Drilling, Intact Osteochondritis Dissecans Lesion W/Int Fixation | Policies naming 29887 |
| 34839 | Not listed | Policies naming 34839 | |
| 36000 | Not listed | Policies naming 36000 | |
| 43235 | On the list | Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | Policies naming 43235 |
| 43770 | On the list | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric ba | Policies naming 43770 |
| 43771 | On the list | Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only | Policies naming 43771 |
| 43772 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only | Policies naming 43772 |
| 43773 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device c | Policies naming 43773 |
| 43774 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous | Policies naming 43774 |
| 43775 | On the list | Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) | Policies naming 43775 |
| 62310 | Not listed | Policies naming 62310 | |
| 62311 | Not listed | Policies naming 62311 | |
| 62319 | Not listed | Policies naming 62319 | |
| 62320 | On the list | Injection(s) of diagnostic or therapeutic substance(s) (eg. anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle | Policies naming 62320 |
| 62321 | On the list | Injection(s) of diagnostic or therapeutic substance(s) (eg. anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle | Policies naming 62321 |
| 62322 | On the list | Injection(s) of diagnostic or therapeutic substances(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution) not including neurolytic substances, including needle | Policies naming 62322 |
| 62323 | On the list | Injection(s) of diagnostic or therapeutic substances(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution) not including neurolytic substances, including needle | Policies naming 62323 |
| 62324 | Not listed | Policies naming 62324 | |
| 62325 | Not listed | Policies naming 62325 | |
| 62326 | Not listed | Policies naming 62326 | |
| 62327 | Not listed | Policies naming 62327 | |
| 63048 | On the list | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis | Policies naming 63048 |
| 63081 | On the list | Vertebral Corpectomy, Anterior; Cervical, 1 Segment | Policies naming 63081 |
| 63088 | On the list | Vertebral Corpectomy, Thoracolumbar, Lower Thoracic/Lumbar; Add'l Segment | Policies naming 63088 |
| 64466 | Not listed | Policies naming 64466 | |
| 64469 | Not listed | Policies naming 64469 | |
| 64473 | Not listed | Policies naming 64473 | |
| 64474 | Not listed | Policies naming 64474 | |
| 69209 | Not listed | Policies naming 69209 | |
| 69210 | Not listed | Policies naming 69210 | |
| 74710 | Not listed | Policies naming 74710 | |
| 76499 | Not listed | Policies naming 76499 | |
| 76604 | Not listed | Policies naming 76604 | |
| 76705 | Not listed | Policies naming 76705 | |
| 76706 | Not listed | Policies naming 76706 | |
| 76770 | Not listed | Policies naming 76770 | |
| 76775 | Not listed | Policies naming 76775 | |
| 76776 | Not listed | Policies naming 76776 | |
| 76815 | Not listed | Policies naming 76815 | |
| 76881 | Not listed | Policies naming 76881 | |
| 76942 | Not listed | Policies naming 76942 | |
| 77002 | Not listed | Policies naming 77002 | |
| 77003 | Not listed | Policies naming 77003 | |
| 77012 | Not listed | Policies naming 77012 | |
| 77014 | Not listed | Policies naming 77014 | |
| 77021 | Not listed | Policies naming 77021 | |
| 77061 | Not listed | Policies naming 77061 | |
| 77062 | Not listed | Policies naming 77062 | |
| 77063 | Not listed | Policies naming 77063 | |
| 77280 | Not listed | Policies naming 77280 | |
| 77285 | Not listed | Policies naming 77285 | |
| 77290 | Not listed | Policies naming 77290 | |
| 80300 | Not listed | Policies naming 80300 | |
| 80301 | Not listed | Policies naming 80301 | |
| 80302 | Not listed | Policies naming 80302 | |
| 80303 | Not listed | Policies naming 80303 | |
| 80304 | Not listed | Policies naming 80304 | |
| 80305 | Not listed | Policies naming 80305 | |
| 80307 | Not listed | Policies naming 80307 | |
| 80320 | Not listed | Policies naming 80320 | |
| 80377 | Not listed | Policies naming 80377 | |
| 81000 | On the list | Urinalysis, Dip Stick/Tablet Reagent; Non-Automated W/Microscopy | Policies naming 81000 |
| 81003 | On the list | Urinalysis, Dip Stick/Tablet Reagent; Automated, W/O Microscopy | Policies naming 81003 |
| 82541 | Not listed | Policies naming 82541 | |
| 82542 | On the list | Column Chromatography/Mass Spectrometry; Quantitative, Single Stationary & Mobile Phase | Policies naming 82542 |
| 82543 | Not listed | Policies naming 82543 | |
| 82544 | Not listed | Policies naming 82544 | |
| 82570 | On the list | Creatinine; Other Source | Policies naming 82570 |
| 83986 | On the list | pH; body fluid, not otherwise specified | Policies naming 83986 |
| 83992 | On the list | Phencyclidine (Pcp) | Policies naming 83992 |
| 88141 | On the list | Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician | Policies naming 88141 |
| 88155 | Not listed | Policies naming 88155 | |
| 88164 | On the list | Cytopathology, Slides, Cervical/Vaginal, Bethesda; Manual Screen | Policies naming 88164 |
| 88174 | On the list | Cytopathology, Cervical/Vaginal, Auto Thin Layer Prep; Auto Screen, W/Phys Interp | Policies naming 88174 |
| 88175 | On the list | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer prepara | Policies naming 88175 |
| 91065 | Not listed | Policies naming 91065 | |
| 93010 | Not listed | Policies naming 93010 | |
| 93042 | Not listed | Policies naming 93042 | |
| 95937 | Not listed | Policies naming 95937 | |
| 95940 | Not listed | Policies naming 95940 | |
| 95941 | Not listed | Policies naming 95941 | |
| 95950 | Not listed | Policies naming 95950 | |
| 95951 | Not listed | Policies naming 95951 | |
| 95953 | Not listed | Policies naming 95953 | |
| 95954 | Not listed | Policies naming 95954 | |
| 95955 | Not listed | Policies naming 95955 | |
| 95956 | Not listed | Policies naming 95956 | |
| 95957 | Not listed | Policies naming 95957 | |
| 96360 | Not listed | Policies naming 96360 | |
| 96365 | On the list | Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour | Policies naming 96365 |
| 96374 | Not listed | Policies naming 96374 | |
| 96375 | Not listed | Policies naming 96375 | |
| 96376 | Not listed | Policies naming 96376 | |
| 96405 | Not listed | Policies naming 96405 | |
| 96406 | Not listed | Policies naming 96406 | |
| 96409 | Not listed | Policies naming 96409 | |
| 96413 | Not listed | Policies naming 96413 | |
| 96416 | Not listed | Policies naming 96416 | |
| 96440 | Not listed | Policies naming 96440 | |
| 96446 | Not listed | Policies naming 96446 | |
| 96450 | Not listed | Policies naming 96450 | |
| 96542 | Not listed | Policies naming 96542 | |
| 97810 | Not listed | Policies naming 97810 | |
| 97814 | Not listed | Policies naming 97814 | |
| 98960 | Not listed | Policies naming 98960 | |
| 98961 | Not listed | Policies naming 98961 | |
| 98962 | Not listed | Policies naming 98962 | |
| 98966 | Not listed | Policies naming 98966 | |
| 98967 | Not listed | Policies naming 98967 | |
| 98968 | Not listed | Policies naming 98968 | |
| 98969 | Not listed | Policies naming 98969 | |
| 99000 | Not listed | Policies naming 99000 | |
| 99001 | Not listed | Policies naming 99001 | |
| 99072 | Not listed | Policies naming 99072 | |
| 99151 | On the list | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation suppor | Policies naming 99151 |
| 99152 | On the list | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation suppor | Policies naming 99152 |
| 99153 | Not listed | Policies naming 99153 | |
| 99155 | On the list | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing | Policies naming 99155 |
| 99156 | On the list | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing | Policies naming 99156 |
| 99157 | Not listed | Policies naming 99157 | |
| 99202 | Not listed | Policies naming 99202 | |
| 99215 | Not listed | Policies naming 99215 | |
| 99217 | Not listed | Policies naming 99217 | |
| 99220 | Not listed | Policies naming 99220 | |
| 99221 | Not listed | Policies naming 99221 | |
| 99224 | Not listed | Policies naming 99224 | |
| 99226 | Not listed | Policies naming 99226 | |
| 99233 | Not listed | Policies naming 99233 | |
| 99241 | Not listed | Policies naming 99241 | |
| 99242 | Not listed | Policies naming 99242 | |
| 99245 | Not listed | Policies naming 99245 | |
| 99251 | Not listed | Policies naming 99251 | |
| 99252 | Not listed | Policies naming 99252 | |
| 99255 | Not listed | Policies naming 99255 | |
| 99281 | Not listed | Policies naming 99281 | |
| 99285 | Not listed | Policies naming 99285 | |
| 99318 | Not listed | Policies naming 99318 | |
| 99324 | Not listed | Policies naming 99324 | |
| 99328 | Not listed | Policies naming 99328 | |
| 99334 | Not listed | Policies naming 99334 | |
| 99337 | Not listed | Policies naming 99337 | |
| 99339 | Not listed | Policies naming 99339 | |
| 99340 | Not listed | Policies naming 99340 | |
| 99354 | Not listed | Policies naming 99354 | |
| 99357 | Not listed | Policies naming 99357 | |
| 99360 | Not listed | Policies naming 99360 | |
| 99363 | Not listed | Policies naming 99363 | |
| 99364 | Not listed | Policies naming 99364 | |
| 99381 | Not listed | Policies naming 99381 | |
| 99397 | Not listed | Policies naming 99397 | |
| 99415 | Not listed | Policies naming 99415 | |
| 99416 | Not listed | Policies naming 99416 | |
| 99420 | Not listed | Policies naming 99420 | |
| 99441 | Not listed | Policies naming 99441 | |
| 99442 | Not listed | Policies naming 99442 | |
| 99443 | Not listed | Policies naming 99443 | |
| 99444 | Not listed | Policies naming 99444 | |
| 99446 | Not listed | Policies naming 99446 | |
| 99447 | Not listed | Policies naming 99447 | |
| 99449 | Not listed | Policies naming 99449 | |
| 99451 | Not listed | Policies naming 99451 | |
| 99452 | Not listed | Policies naming 99452 | |
| 99484 | Not listed | Policies naming 99484 | |
| 99487 | Not listed | Policies naming 99487 | |
| 99490 | Not listed | Policies naming 99490 | |
| 99495 | Not listed | Policies naming 99495 | |
| 99496 | Not listed | Policies naming 99496 | |
| 99497 | Not listed | Policies naming 99497 | |
| 99498 | Not listed | Policies naming 99498 | |
| 99602 | On the list | Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in additio | Policies naming 99602 |
| A4215 | Not listed | Policies naming A4215 | |
| A4281 | Not listed | Policies naming A4281 | |
| A4282 | Not listed | Policies naming A4282 | |
| A4283 | Not listed | Policies naming A4283 | |
| A4284 | Not listed | Policies naming A4284 | |
| A4285 | Not listed | Policies naming A4285 | |
| A4556 | Not listed | Policies naming A4556 | |
| A4557 | Not listed | Policies naming A4557 | |
| A4558 | Not listed | Policies naming A4558 | |
| A4580 | Not listed | Policies naming A4580 | |
| A4590 | Not listed | Policies naming A4590 | |
| A4595 | Not listed | Policies naming A4595 | |
| A4648 | Not listed | Policies naming A4648 | |
| C9032 | Not listed | Policies naming C9032 | |
| C9257 | On the list | Injection, bevacizumab, 0.25 mg | Policies naming C9257 |
| E0602 | Not listed | Policies naming E0602 | |
| E0603 | Not listed | Policies naming E0603 | |
| E0604 | Not listed | Policies naming E0604 | |
| E0776 | Not listed | Policies naming E0776 | |
| G0101 | Not listed | Policies naming G0101 | |
| G0180 | Not listed | Policies naming G0180 | |
| G0268 | Not listed | Policies naming G0268 | |
| G0276 | Not listed | Policies naming G0276 | |
| G0279 | Not listed | Policies naming G0279 | |
| G0310 | Not listed | Policies naming G0310 | |
| G0311 | Not listed | Policies naming G0311 | |
| G0312 | Not listed | Policies naming G0312 | |
| G0313 | Not listed | Policies naming G0313 | |
| G0314 | Not listed | Policies naming G0314 | |
| G0315 | Not listed | Policies naming G0315 | |
| G0316 | Not listed | Policies naming G0316 | |
| G0318 | Not listed | Policies naming G0318 | |
| G0402 | Not listed | Policies naming G0402 | |
| G0431 | Not listed | Policies naming G0431 | |
| G0434 | Not listed | Policies naming G0434 | |
| G0438 | Not listed | Policies naming G0438 | |
| G0439 | Not listed | Policies naming G0439 | |
| G0453 | Not listed | Policies naming G0453 | |
| G0466 | Not listed | Policies naming G0466 | |
| G0470 | Not listed | Policies naming G0470 | |
| G0477 | Not listed | Policies naming G0477 | |
| G0478 | Not listed | Policies naming G0478 | |
| G0479 | Not listed | Policies naming G0479 | |
| G0480 | Not listed | Policies naming G0480 | |
| G0483 | Not listed | Policies naming G0483 | |
| G0498 | Not listed | Policies naming G0498 | |
| G0500 | Not listed | Policies naming G0500 | |
| G0501 | Not listed | Policies naming G0501 | |
| G0502 | Not listed | Policies naming G0502 | |
| G0503 | Not listed | Policies naming G0503 | |
| G0504 | Not listed | Policies naming G0504 | |
| G0507 | Not listed | Policies naming G0507 | |
| G0659 | Not listed | Policies naming G0659 | |
| G0913 | Not listed | Policies naming G0913 | |
| G0918 | Not listed | Policies naming G0918 | |
| G2212 | Not listed | Policies naming G2212 | |
| G2221 | Not listed | Policies naming G2221 | |
| G9038 | Not listed | Policies naming G9038 | |
| G9481 | Not listed | Policies naming G9481 | |
| G9678 | Not listed | Policies naming G9678 | |
| H0048 | On the list | Alcohol and/or other drug testing: collection and handling only, specimens other than blood | Policies naming H0048 |
| J2001 | Not listed | Policies naming J2001 | |
| J2004 | Not listed | Policies naming J2004 | |
| J3490 | Not listed | Policies naming J3490 | |
| L3000 | Not listed | Policies naming L3000 | |
| L3010 | Not listed | Policies naming L3010 | |
| L3020 | Not listed | Policies naming L3020 | |
| L3030 | Not listed | Policies naming L3030 | |
| M0001 | Not listed | Policies naming M0001 | |
| M0005 | Not listed | Policies naming M0005 | |
| M1150 | Not listed | Policies naming M1150 | |
| M1210 | Not listed | Policies naming M1210 | |
| Q0516 | Not listed | Policies naming Q0516 | |
| Q0520 | Not listed | Policies naming Q0520 | |
| Q0521 | Not listed | Policies naming Q0521 | |
| Q3014 | Not listed | Policies naming Q3014 | |
| Q9977 | Not listed | Policies naming Q9977 | |
| S0189 | Not listed | Policies naming S0189 | |
| S0257 | Not listed | Policies naming S0257 | |
| S0310 | Not listed | Policies naming S0310 | |
| S0315 | Not listed | Policies naming S0315 | |
| S0317 | Not listed | Policies naming S0317 | |
| S0353 | On the list | Treatment planning and care coordination management for cancer initial treatment | Policies naming S0353 |
| S0354 | On the list | Treatment planning and care coordination management for cancer established patient with a change of regimen | Policies naming S0354 |
And 41 more in the original policy.
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list