Anthem Blue Cross and Blue Shield Virginia policy
Frequency Editing - Professional
Frequency Editing - Professional is a public Anthem Blue Cross and Blue Shield Virginia policy (policy C-08012, effective Mar 1, 2025). It lists 214 CPT or HCPCS codes, 53 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-08012
- Effective
- Mar 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 |
|---|---|---|---|
| 0403T | Not listed | Policies naming 0403T | |
| 08012 | Not listed | Policies naming 08012 | |
| 10001 | Not listed | Policies naming 10001 | |
| 11003 | Not listed | Policies naming 11003 | |
| 11720 | Not listed | Policies naming 11720 | |
| 11721 | Not listed | Policies naming 11721 | |
| 12004 | Not listed | Policies naming 12004 | |
| 36146 | Not listed | Policies naming 36146 | |
| 36415 | Not listed | Policies naming 36415 | |
| 36416 | Not listed | Policies naming 36416 | |
| 49185 | Not listed | Policies naming 49185 | |
| 76942 | Not listed | Policies naming 76942 | |
| 77002 | Not listed | Policies naming 77002 | |
| 77003 | Not listed | Policies naming 77003 | |
| 77012 | Not listed | Policies naming 77012 | |
| 77021 | Not listed | Policies naming 77021 | |
| 77338 | On the list | Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT | Policies naming 77338 |
| 77600 | Not listed | Policies naming 77600 | |
| 77605 | Not listed | Policies naming 77605 | |
| 80320 | Not listed | Policies naming 80320 | |
| 80321 | Not listed | Policies naming 80321 | |
| 80322 | Not listed | Policies naming 80322 | |
| 80324 | Not listed | Policies naming 80324 | |
| 80337 | Not listed | Policies naming 80337 | |
| 80339 | Not listed | Policies naming 80339 | |
| 80344 | Not listed | Policies naming 80344 | |
| 80346 | Not listed | Policies naming 80346 | |
| 80347 | Not listed | Policies naming 80347 | |
| 80350 | Not listed | Policies naming 80350 | |
| 80352 | Not listed | Policies naming 80352 | |
| 80361 | Not listed | Policies naming 80361 | |
| 80364 | Not listed | Policies naming 80364 | |
| 80369 | Not listed | Policies naming 80369 | |
| 80370 | Not listed | Policies naming 80370 | |
| 80375 | Not listed | Policies naming 80375 | |
| 80377 | Not listed | Policies naming 80377 | |
| 81479 | On the list | Unlisted molecular pathology procedure | Policies naming 81479 |
| 81528 | Not listed | Policies naming 81528 | |
| 83992 | On the list | Phencyclidine (Pcp) | Policies naming 83992 |
| 86160 | On the list | Complement; Antigen, Each Component | Policies naming 86160 |
| 87483 | On the list | Infectious agent detection by nucleic acid (DNA or RNA); central nervous system pathogen (eg, Neisseria meningitidis, Streptococcus pneumoniae, Listeria, Haemophilus influenza | Policies naming 87483 |
| 87491 | On the list | Infectious Agent, Nucleic Acid (Dna/Rna); Chlamydia Trachomatis, Amplified Probe | Policies naming 87491 |
| 87529 | On the list | Infectious Agent, Nucleic Acid (Dna/Rna); Herpes Simplex Virus, Amplified Probe | Policies naming 87529 |
| 87591 | On the list | Infectious Agent, Nucleic Acid (Dna/Rna); Neisseria Gonorrhoeae, Amplified Probe | Policies naming 87591 |
| 88305 | On the list | Level Iv - Surgical Pathology, Gross & Microscopic Exam | Policies naming 88305 |
| 90378 | On the list | Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each | Policies naming 90378 |
| 90471 | Not listed | Policies naming 90471 | |
| 90473 | Not listed | Policies naming 90473 | |
| 90767 | Not listed | Policies naming 90767 | |
| 90791 | Not listed | Policies naming 90791 | |
| 90792 | Not listed | Policies naming 90792 | |
| 90951 | Not listed | Policies naming 90951 | |
| 90962 | Not listed | Policies naming 90962 | |
| 90963 | Not listed | Policies naming 90963 | |
| 90966 | Not listed | Policies naming 90966 | |
| 91065 | Not listed | Policies naming 91065 | |
| 92250 | Not listed | Policies naming 92250 | |
| 92273 | Not listed | Policies naming 92273 | |
| 92274 | Not listed | Policies naming 92274 | |
| 92275 | Not listed | Policies naming 92275 | |
| 92326 | Not listed | Policies naming 92326 | |
| 93012 | Not listed | Policies naming 93012 | |
| 93293 | Not listed | Policies naming 93293 | |
| 93296 | Not listed | Policies naming 93296 | |
| 93297 | Not listed | Policies naming 93297 | |
| 93299 | Not listed | Policies naming 93299 | |
| 93325 | Not listed | Policies naming 93325 | |
| 93792 | Not listed | Policies naming 93792 | |
| 93793 | Not listed | Policies naming 93793 | |
| 94014 | Not listed | Policies naming 94014 | |
| 94016 | Not listed | Policies naming 94016 | |
| 94774 | Not listed | Policies naming 94774 | |
| 94777 | Not listed | Policies naming 94777 | |
| 95165 | Not listed | Policies naming 95165 | |
| 95250 | Not listed | Policies naming 95250 | |
| 95251 | Not listed | Policies naming 95251 | |
| 95782 | On the list | Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist | Policies naming 95782 |
| 95783 | On the list | Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level | Policies naming 95783 |
| 95800 | On the list | Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time | Policies naming 95800 |
| 95801 | On the list | Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone) | Policies naming 95801 |
| 95806 | On the list | Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory | Policies naming 95806 |
| 95807 | On the list | Sleep Study, Attended | Policies naming 95807 |
| 95808 | On the list | Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist | Policies naming 95808 |
| 95810 | On the list | Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist | Policies naming 95810 |
| 95811 | On the list | Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel v | Policies naming 95811 |
| 95925 | Not listed | Policies naming 95925 | |
| 95926 | Not listed | Policies naming 95926 | |
| 95927 | Not listed | Policies naming 95927 | |
| 95928 | Not listed | Policies naming 95928 | |
| 95929 | Not listed | Policies naming 95929 | |
| 95938 | Not listed | Policies naming 95938 | |
| 95939 | Not listed | Policies naming 95939 | |
| 96014 | Not listed | Policies naming 96014 | |
| 96116 | Not listed | Policies naming 96116 | |
| 96150 | Not listed | Policies naming 96150 | |
| 96152 | Not listed | Policies naming 96152 | |
| 96154 | Not listed | Policies naming 96154 | |
| 96155 | Not listed | Policies naming 96155 | |
| 96158 | Not listed | Policies naming 96158 | |
| 96159 | Not listed | Policies naming 96159 | |
| 96164 | Not listed | Policies naming 96164 | |
| 96165 | Not listed | Policies naming 96165 | |
| 96367 | Not listed | Policies naming 96367 | |
| 96401 | Not listed | Policies naming 96401 | |
| 96416 | Not listed | Policies naming 96416 | |
| 96516 | Not listed | Policies naming 96516 | |
| 96900 | Not listed | Policies naming 96900 | |
| 97012 | On the list | Application of a modality to 1 or more areas; traction, mechanical | Policies naming 97012 |
| 97016 | On the list | Application of a modality to 1 or more areas; vasopneumatic devices | Policies naming 97016 |
| 97018 | On the list | Application of a modality to 1 or more areas; paraffin bath | Policies naming 97018 |
| 97022 | On the list | Application of a modality to 1 or more areas; whirlpool | Policies naming 97022 |
| 97024 | On the list | Application of a modality to 1 or more areas; diathermy (eg, microwave) | Policies naming 97024 |
| 97026 | On the list | Application of a modality to 1 or more areas; infrared | Policies naming 97026 |
| 97028 | On the list | Application of a modality to 1 or more areas; ultraviolet | Policies naming 97028 |
| 99183 | On the list | Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session | Policies naming 99183 |
| 99363 | Not listed | Policies naming 99363 | |
| 99364 | Not listed | Policies naming 99364 | |
| A4224 | Not listed | Policies naming A4224 | |
| A4230 | Not listed | Policies naming A4230 | |
| A4231 | Not listed | Policies naming A4231 | |
| A4232 | Not listed | Policies naming A4232 | |
| A4238 | Not listed | Policies naming A4238 | |
| A4239 | Not listed | Policies naming A4239 | |
| A4244 | Not listed | Policies naming A4244 | |
| A4245 | Not listed | Policies naming A4245 | |
| A4250 | Not listed | Policies naming A4250 | |
| A4253 | Not listed | Policies naming A4253 | |
| A4259 | Not listed | Policies naming A4259 | |
| A4556 | Not listed | Policies naming A4556 | |
| A4557 | Not listed | Policies naming A4557 | |
| A4595 | Not listed | Policies naming A4595 | |
| A6520 | Not listed | Policies naming A6520 | |
| A6529 | Not listed | Policies naming A6529 | |
| A6530 | Not listed | Policies naming A6530 | |
| A6541 | Not listed | Policies naming A6541 | |
| A6545 | Not listed | Policies naming A6545 | |
| A6549 | Not listed | Policies naming A6549 | |
| A6552 | Not listed | Policies naming A6552 | |
| A6589 | Not listed | Policies naming A6589 | |
| A6593 | Not listed | Policies naming A6593 | |
| A6610 | Not listed | Policies naming A6610 | |
| A9276 | Not listed | Policies naming A9276 | |
| C9257 | On the list | Injection, bevacizumab, 0.25 mg | Policies naming C9257 |
| E0441 | Not listed | Policies naming E0441 | |
| E0444 | Not listed | Policies naming E0444 | |
| E0602 | Not listed | Policies naming E0602 | |
| E0603 | Not listed | Policies naming E0603 | |
| E0604 | Not listed | Policies naming E0604 | |
| E1812 | Not listed | Policies naming E1812 | |
| G0249 | Not listed | Policies naming G0249 | |
| G0308 | Not listed | Policies naming G0308 | |
| G0319 | Not listed | Policies naming G0319 | |
| G0398 | On the list | Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart r | Policies naming G0398 |
| G0399 | On the list | Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow | Policies naming G0399 |
| G0400 | On the list | Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels | Policies naming G0400 |
| G0416 | On the list | Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method, 10-20 specimens | Policies naming G0416 |
| G0431 | Not listed | Policies naming G0431 | |
| G0434 | Not listed | Policies naming G0434 | |
| G0477 | Not listed | Policies naming G0477 | |
| G0479 | Not listed | Policies naming G0479 | |
| G0480 | Not listed | Policies naming G0480 | |
| G0481 | Not listed | Policies naming G0481 | |
| G0482 | Not listed | Policies naming G0482 | |
| G0483 | Not listed | Policies naming G0483 | |
| G2066 | Not listed | Policies naming G2066 | |
| H0020 | Not listed | Policies naming H0020 | |
| H0022 | Not listed | Policies naming H0022 | |
| J0129 | On the list | Injection, abatacept, 10 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) | Policies naming J0129 |
| J0585 | On the list | Injection, Onabotulinumtoxina, 1 Unit | Policies naming J0585 |
| J0586 | On the list | Injection, Abobotulinumtoxina, 5 Units | Policies naming J0586 |
| J0696 | On the list | Ceftriaxone Sodium Injection | Policies naming J0696 |
| J0717 | On the list | Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administer | Policies naming J0717 |
| J0897 | On the list | Injection, denosumab, 1 mg | Policies naming J0897 |
| J1453 | Not listed | Policies naming J1453 | |
| J1460 | On the list | Gamma Globulin 1 Cc Inj | Policies naming J1460 |
| J1470 | Not listed | Policies naming J1470 | |
| J1550 | Not listed | Policies naming J1550 | |
| J1560 | On the list | Gamma Globulin > 10 Cc Inj | Policies naming J1560 |
| J1750 | Not listed | Policies naming J1750 | |
| J2353 | On the list | Injection, octreotide, depot form for intramuscular injection, 1 mg | Policies naming J2353 |
| J2357 | On the list | Omalizumab injection | Policies naming J2357 |
| J2469 | Not listed | Policies naming J2469 | |
| J2505 | Not listed | Policies naming J2505 | |
| J2507 | On the list | Injection, pegloticase, 1 mg | Policies naming J2507 |
| J2800 | Not listed | Policies naming J2800 | |
| J3357 | On the list | Ustekinumab, for subcutaneous injection, 1 mg | Policies naming J3357 |
| J3489 | On the list | Injection, zoledronic acid, 1 mg | Policies naming J3489 |
| J7307 | Not listed | Policies naming J7307 | |
| J7312 | On the list | Injection, dexamethasone, intravitreal implant, 0.1 mg | Policies naming J7312 |
| J7320 | Not listed | Policies naming J7320 | |
| J7321 | Not listed | Policies naming J7321 | |
| J7322 | Not listed | Policies naming J7322 | |
| J7323 | Not listed | Policies naming J7323 | |
| J7324 | Not listed | Policies naming J7324 | |
| J7325 | Not listed | Policies naming J7325 | |
| J7326 | Not listed | Policies naming J7326 | |
| J9030 | Not listed | Policies naming J9030 | |
| J9031 | Not listed | Policies naming J9031 | |
| J9047 | On the list | Injection, carfilzomib, 1 mg | Policies naming J9047 |
| J9202 | On the list | Goserelin Acetate Implant | Policies naming J9202 |
| J9217 | On the list | Leuprolide Acetate Suspnsion | Policies naming J9217 |
| J9351 | Not listed | Policies naming J9351 | |
| J9355 | Not listed | Policies naming J9355 | |
| J9356 | Not listed | Policies naming J9356 | |
| J9395 | Not listed | Policies naming J9395 | |
| Q0509 | Not listed | Policies naming Q0509 | |
| Q4101 | On the list | Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4101 |
| S9123 | On the list | Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT cod | Policies naming S9123 |
| S9124 | On the list | Nursing care, in the home; by licensed practical nurse, per hour | Policies naming S9124 |
| S9140 | Not listed | Policies naming S9140 | |
| S9141 | Not listed | Policies naming S9141 | |
| S9529 | Not listed | Policies naming S9529 | |
| V5267 | Not listed | Policies naming V5267 | |
| V5298 | On the list | Hearing Aid, Not Otherwise Classified | Policies naming V5298 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list