Anthem Blue Cross and Blue Shield Virginia policy
CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting is a public Anthem Blue Cross and Blue Shield Virginia policy (policy CG-MED-41). It lists 10 CPT or HCPCS codes, 8 of them on the Anthem Blue Cross and Blue Shield Virginia prior authorization list. Not a coverage decision; the payer's own document governs.
Check eligibility for free
No account required. Sign a BAA to see plan details, coordination of benefits and more
- Policy number
- CG-MED-41
- Line of business
- Commercial
- 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 |
|---|---|---|---|
| 00170 | On the list | Anesthesia, Intraoral Proc, W/Bx; Nos | Policies naming 00170 |
| 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 | |
| D9222 | On the list | deep sedation/general anesthesia - first 15 minutes | Policies naming D9222 |
| D9223 | On the list | deep sedation/general anesthesia - each subsequent 15 minute increment | Policies naming D9223 |
| G0330 | On the list | Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia ca | Policies naming G0330 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list