Anthem Blue Cross and Blue Shield Virginia policy
HEDIS measurement year 2023–2024
HEDIS measurement year 2023–2024 is a public Anthem Blue Cross and Blue Shield Virginia policy. It lists 451 CPT or HCPCS codes, 54 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) ↗
Check eligibility for free
No account required. Sign a BAA to see plan details, coordination of benefits and more
- Line of business
- Commercial, Medicaid
- 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 |
|---|---|---|---|
| 0500F | Not listed | Policies naming 0500F | |
| 0501F | Not listed | Policies naming 0501F | |
| 0502F | Not listed | Policies naming 0502F | |
| 0503F | Not listed | Policies naming 0503F | |
| 1111F | Not listed | Policies naming 1111F | |
| 1125F | Not listed | Policies naming 1125F | |
| 1126F | Not listed | Policies naming 1126F | |
| 1159F | Not listed | Policies naming 1159F | |
| 1160F | Not listed | Policies naming 1160F | |
| 1170F | Not listed | Policies naming 1170F | |
| 19300 | On the list | Mastectomy for gynecomastia | Policies naming 19300 |
| 19307 | Not listed | Policies naming 19307 | |
| 2022F | Not listed | Policies naming 2022F | |
| 2023F | Not listed | Policies naming 2023F | |
| 2024F | Not listed | Policies naming 2024F | |
| 2025F | Not listed | Policies naming 2025F | |
| 2026F | Not listed | Policies naming 2026F | |
| 2033F | Not listed | Policies naming 2033F | |
| 3044F | Not listed | Policies naming 3044F | |
| 3046F | Not listed | Policies naming 3046F | |
| 3051F | Not listed | Policies naming 3051F | |
| 3052F | Not listed | Policies naming 3052F | |
| 3072F | Not listed | Policies naming 3072F | |
| 3074F | Not listed | Policies naming 3074F | |
| 3075F | Not listed | Policies naming 3075F | |
| 3077F | Not listed | Policies naming 3077F | |
| 3078F | Not listed | Policies naming 3078F | |
| 3079F | Not listed | Policies naming 3079F | |
| 3080F | Not listed | Policies naming 3080F | |
| 44388 | Not listed | Policies naming 44388 | |
| 44389 | Not listed | Policies naming 44389 | |
| 44390 | Not listed | Policies naming 44390 | |
| 44392 | Not listed | Policies naming 44392 | |
| 44401 | Not listed | Policies naming 44401 | |
| 44408 | Not listed | Policies naming 44408 | |
| 45330 | Not listed | Policies naming 45330 | |
| 45335 | Not listed | Policies naming 45335 | |
| 45337 | Not listed | Policies naming 45337 | |
| 45338 | Not listed | Policies naming 45338 | |
| 45346 | Not listed | Policies naming 45346 | |
| 45347 | Not listed | Policies naming 45347 | |
| 45349 | Not listed | Policies naming 45349 | |
| 45350 | Not listed | Policies naming 45350 | |
| 45352 | Not listed | Policies naming 45352 | |
| 45378 | Not listed | Policies naming 45378 | |
| 45379 | Not listed | Policies naming 45379 | |
| 45380 | Not listed | Policies naming 45380 | |
| 45382 | Not listed | Policies naming 45382 | |
| 45384 | Not listed | Policies naming 45384 | |
| 45386 | Not listed | Policies naming 45386 | |
| 45388 | Not listed | Policies naming 45388 | |
| 45389 | Not listed | Policies naming 45389 | |
| 45390 | Not listed | Policies naming 45390 | |
| 45393 | Not listed | Policies naming 45393 | |
| 45398 | Not listed | Policies naming 45398 | |
| 57170 | Not listed | Policies naming 57170 | |
| 58300 | Not listed | Policies naming 58300 | |
| 59400 | Not listed | Policies naming 59400 | |
| 59409 | Not listed | Policies naming 59409 | |
| 59410 | Not listed | Policies naming 59410 | |
| 59425 | Not listed | Policies naming 59425 | |
| 59426 | Not listed | Policies naming 59426 | |
| 59430 | Not listed | Policies naming 59430 | |
| 59510 | Not listed | Policies naming 59510 | |
| 59514 | Not listed | Policies naming 59514 | |
| 59515 | Not listed | Policies naming 59515 | |
| 59610 | Not listed | Policies naming 59610 | |
| 59612 | Not listed | Policies naming 59612 | |
| 59614 | Not listed | Policies naming 59614 | |
| 59618 | Not listed | Policies naming 59618 | |
| 59620 | Not listed | Policies naming 59620 | |
| 59622 | Not listed | Policies naming 59622 | |
| 65091 | Not listed | Policies naming 65091 | |
| 65093 | Not listed | Policies naming 65093 | |
| 65101 | Not listed | Policies naming 65101 | |
| 65103 | Not listed | Policies naming 65103 | |
| 65105 | Not listed | Policies naming 65105 | |
| 65110 | Not listed | Policies naming 65110 | |
| 65112 | Not listed | Policies naming 65112 | |
| 65114 | Not listed | Policies naming 65114 | |
| 67028 | Not listed | Policies naming 67028 | |
| 67030 | Not listed | Policies naming 67030 | |
| 67031 | Not listed | Policies naming 67031 | |
| 67036 | Not listed | Policies naming 67036 | |
| 67039 | Not listed | Policies naming 67039 | |
| 67040 | Not listed | Policies naming 67040 | |
| 67041 | Not listed | Policies naming 67041 | |
| 67042 | Not listed | Policies naming 67042 | |
| 67043 | Not listed | Policies naming 67043 | |
| 67101 | Not listed | Policies naming 67101 | |
| 67105 | Not listed | Policies naming 67105 | |
| 67107 | Not listed | Policies naming 67107 | |
| 67108 | Not listed | Policies naming 67108 | |
| 67110 | Not listed | Policies naming 67110 | |
| 67113 | Not listed | Policies naming 67113 | |
| 67121 | Not listed | Policies naming 67121 | |
| 67141 | Not listed | Policies naming 67141 | |
| 67145 | Not listed | Policies naming 67145 | |
| 67208 | Not listed | Policies naming 67208 | |
| 67210 | Not listed | Policies naming 67210 | |
| 67218 | On the list | Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; radiation by implantation of | Policies naming 67218 |
| 67220 | Not listed | Policies naming 67220 | |
| 67221 | Not listed | Policies naming 67221 | |
| 67227 | Not listed | Policies naming 67227 | |
| 67228 | Not listed | Policies naming 67228 | |
| 74261 | On the list | Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material | Policies naming 74261 |
| 74263 | On the list | Computed tomographic (CT) colonography, screening, including image postprocessing | Policies naming 74263 |
| 77061 | Not listed | Policies naming 77061 | |
| 77063 | Not listed | Policies naming 77063 | |
| 77065 | Not listed | Policies naming 77065 | |
| 77067 | Not listed | Policies naming 77067 | |
| 80047 | On the list | Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (8256 | Policies naming 80047 |
| 80048 | On the list | Basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) G | Policies naming 80048 |
| 80050 | On the list | General Health Panel | Policies naming 80050 |
| 80053 | On the list | Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, t | Policies naming 80053 |
| 80069 | On the list | Renal function panel This panel must include the following: Albumin (82040) Calcium, total (82310) Carbon dioxide (bicar | Policies naming 80069 |
| 81528 | Not listed | Policies naming 81528 | |
| 82270 | On the list | Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patie | Policies naming 82270 |
| 82274 | On the list | Blood, Occult, Fecal Hemoglobin Determin, Immunoassay, Qualitative, Feces, 1-3 Simultan Determin | Policies naming 82274 |
| 82947 | Not listed | Policies naming 82947 | |
| 82950 | Not listed | Policies naming 82950 | |
| 82951 | Not listed | Policies naming 82951 | |
| 83036 | Not listed | Policies naming 83036 | |
| 83037 | Not listed | Policies naming 83037 | |
| 87624 | On the list | Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68), pooled result | Policies naming 87624 |
| 87625 | On the list | Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed | Policies naming 87625 |
| 88141 | On the list | Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician | Policies naming 88141 |
| 88143 | On the list | Cytopathology, Cervical/Vaginal, Preservative Fluid, Auto Thin Layer Prep; Manual Screen/Rescreen | Policies naming 88143 |
| 88147 | On the list | Cytopathology, Cervical/Vaginal; Automated Screen | Policies naming 88147 |
| 88148 | On the list | Cytopathology, Cervical/Vaginal; Automated Screen, Manual Rescreen | Policies naming 88148 |
| 88150 | On the list | Cytopathology, Slides, Cervical/Vaginal; Manual Screen | Policies naming 88150 |
| 88152 | On the list | Cytopathology, Slides, Cervical/Vaginal; Manual Screen, Computer Rescreen | Policies naming 88152 |
| 88154 | Not listed | Policies naming 88154 | |
| 88164 | On the list | Cytopathology, Slides, Cervical/Vaginal, Bethesda; Manual Screen | Policies naming 88164 |
| 88167 | On the list | Cytopathology, Slides, Cervical/Vaginal, Bethesda; Manual Screen, Computer Rescreen, Cell Selection | Policies naming 88167 |
| 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 |
| 90619 | Not listed | Policies naming 90619 | |
| 90633 | Not listed | Policies naming 90633 | |
| 90644 | Not listed | Policies naming 90644 | |
| 90647 | Not listed | Policies naming 90647 | |
| 90648 | Not listed | Policies naming 90648 | |
| 90649 | Not listed | Policies naming 90649 | |
| 90650 | Not listed | Policies naming 90650 | |
| 90651 | Not listed | Policies naming 90651 | |
| 90655 | Not listed | Policies naming 90655 | |
| 90657 | Not listed | Policies naming 90657 | |
| 90661 | Not listed | Policies naming 90661 | |
| 90670 | Not listed | Policies naming 90670 | |
| 90673 | Not listed | Policies naming 90673 | |
| 90680 | Not listed | Policies naming 90680 | |
| 90681 | Not listed | Policies naming 90681 | |
| 90685 | Not listed | Policies naming 90685 | |
| 90686 | Not listed | Policies naming 90686 | |
| 90687 | Not listed | Policies naming 90687 | |
| 90688 | Not listed | Policies naming 90688 | |
| 90689 | Not listed | Policies naming 90689 | |
| 90697 | Not listed | Policies naming 90697 | |
| 90698 | Not listed | Policies naming 90698 | |
| 90700 | Not listed | Policies naming 90700 | |
| 90707 | Not listed | Policies naming 90707 | |
| 90710 | Not listed | Policies naming 90710 | |
| 90713 | Not listed | Policies naming 90713 | |
| 90715 | Not listed | Policies naming 90715 | |
| 90716 | Not listed | Policies naming 90716 | |
| 90723 | Not listed | Policies naming 90723 | |
| 90733 | Not listed | Policies naming 90733 | |
| 90734 | Not listed | Policies naming 90734 | |
| 90740 | Not listed | Policies naming 90740 | |
| 90744 | Not listed | Policies naming 90744 | |
| 90747 | Not listed | Policies naming 90747 | |
| 90748 | Not listed | Policies naming 90748 | |
| 90791 | Not listed | Policies naming 90791 | |
| 90792 | Not listed | Policies naming 90792 | |
| 90832 | Not listed | Policies naming 90832 | |
| 90834 | Not listed | Policies naming 90834 | |
| 90836 | Not listed | Policies naming 90836 | |
| 90840 | Not listed | Policies naming 90840 | |
| 90847 | Not listed | Policies naming 90847 | |
| 90853 | Not listed | Policies naming 90853 | |
| 90863 | Not listed | Policies naming 90863 | |
| 90870 | Not listed | Policies naming 90870 | |
| 90875 | On the list | Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior m | Policies naming 90875 |
| 90876 | On the list | Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior m | Policies naming 90876 |
| 92002 | Not listed | Policies naming 92002 | |
| 92004 | Not listed | Policies naming 92004 | |
| 92012 | Not listed | Policies naming 92012 | |
| 92014 | Not listed | Policies naming 92014 | |
| 92018 | Not listed | Policies naming 92018 | |
| 92019 | Not listed | Policies naming 92019 | |
| 92134 | Not listed | Policies naming 92134 | |
| 92201 | Not listed | Policies naming 92201 | |
| 92202 | Not listed | Policies naming 92202 | |
| 92230 | Not listed | Policies naming 92230 | |
| 92235 | Not listed | Policies naming 92235 | |
| 92240 | Not listed | Policies naming 92240 | |
| 92250 | Not listed | Policies naming 92250 | |
| 92260 | Not listed | Policies naming 92260 | |
| 97802 | Not listed | Policies naming 97802 | |
| 97804 | Not listed | Policies naming 97804 | |
| 98960 | Not listed | Policies naming 98960 | |
| 98962 | Not listed | Policies naming 98962 | |
| 98966 | Not listed | Policies naming 98966 | |
| 98968 | Not listed | Policies naming 98968 | |
| 98969 | Not listed | Policies naming 98969 | |
| 98970 | Not listed | Policies naming 98970 | |
| 98972 | Not listed | Policies naming 98972 | |
| 99078 | Not listed | Policies naming 99078 | |
| 99202 | Not listed | Policies naming 99202 | |
| 99203 | Not listed | Policies naming 99203 | |
| 99204 | Not listed | Policies naming 99204 | |
| 99205 | Not listed | Policies naming 99205 | |
| 99211 | Not listed | Policies naming 99211 | |
| 99213 | Not listed | Policies naming 99213 | |
| 99214 | Not listed | Policies naming 99214 | |
| 99215 | Not listed | Policies naming 99215 | |
| 99217 | Not listed | Policies naming 99217 | |
| 99220 | Not listed | Policies naming 99220 | |
| 99221 | Not listed | Policies naming 99221 | |
| 99223 | Not listed | Policies naming 99223 | |
| 99227 | Not listed | Policies naming 99227 | |
| 99228 | Not listed | Policies naming 99228 | |
| 99231 | Not listed | Policies naming 99231 | |
| 99233 | Not listed | Policies naming 99233 | |
| 99238 | Not listed | Policies naming 99238 | |
| 99239 | Not listed | Policies naming 99239 | |
| 99241 | Not listed | Policies naming 99241 | |
| 99242 | Not listed | Policies naming 99242 | |
| 99243 | Not listed | Policies naming 99243 | |
| 99244 | Not listed | Policies naming 99244 | |
| 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 | |
| 99291 | Not listed | Policies naming 99291 | |
| 99304 | Not listed | Policies naming 99304 | |
| 99310 | Not listed | Policies naming 99310 | |
| 99315 | Not listed | Policies naming 99315 | |
| 99316 | Not listed | Policies naming 99316 | |
| 99318 | Not listed | Policies naming 99318 | |
| 99341 | Not listed | Policies naming 99341 | |
| 99345 | Not listed | Policies naming 99345 | |
| 99347 | Not listed | Policies naming 99347 | |
| 99349 | Not listed | Policies naming 99349 | |
| 99350 | Not listed | Policies naming 99350 | |
| 99377 | Not listed | Policies naming 99377 | |
| 99378 | Not listed | Policies naming 99378 | |
| 99381 | Not listed | Policies naming 99381 | |
| 99385 | Not listed | Policies naming 99385 | |
| 99387 | Not listed | Policies naming 99387 | |
| 99391 | Not listed | Policies naming 99391 | |
| 99395 | Not listed | Policies naming 99395 | |
| 99397 | Not listed | Policies naming 99397 | |
| 99401 | Not listed | Policies naming 99401 | |
| 99403 | Not listed | Policies naming 99403 | |
| 99404 | Not listed | Policies naming 99404 | |
| 99411 | Not listed | Policies naming 99411 | |
| 99412 | Not listed | Policies naming 99412 | |
| 99421 | Not listed | Policies naming 99421 | |
| 99423 | Not listed | Policies naming 99423 | |
| 99429 | Not listed | Policies naming 99429 | |
| 99441 | Not listed | Policies naming 99441 | |
| 99443 | Not listed | Policies naming 99443 | |
| 99455 | Not listed | Policies naming 99455 | |
| 99456 | Not listed | Policies naming 99456 | |
| 99457 | Not listed | Policies naming 99457 | |
| 99461 | Not listed | Policies naming 99461 | |
| 99483 | Not listed | Policies naming 99483 | |
| 99492 | Not listed | Policies naming 99492 | |
| 99494 | Not listed | Policies naming 99494 | |
| 99495 | Not listed | Policies naming 99495 | |
| 99496 | Not listed | Policies naming 99496 | |
| 99500 | On the list | Home Visit, Prenat Monitor Assess, Fetal Heart Rate, Non-Stress Test, Uterine, Gestat Diabet Monitor | Policies naming 99500 |
| 99501 | Not listed | Policies naming 99501 | |
| 99504 | On the list | Home Visit, Mechanical Ventilation Care | Policies naming 99504 |
| 99509 | On the list | Home Visit, Assistance W/Activities Daily Living & Personal Care | Policies naming 99509 |
| 99510 | Not listed | Policies naming 99510 | |
| 99605 | Not listed | Policies naming 99605 | |
| 99606 | Not listed | Policies naming 99606 | |
| 99968 | Not listed | Policies naming 99968 | |
| E0100 | Not listed | Policies naming E0100 | |
| E0105 | Not listed | Policies naming E0105 | |
| E0130 | Not listed | Policies naming E0130 | |
| E0135 | Not listed | Policies naming E0135 | |
| E0140 | Not listed | Policies naming E0140 | |
| E0141 | Not listed | Policies naming E0141 | |
| E0144 | Not listed | Policies naming E0144 | |
| E0147 | Not listed | Policies naming E0147 | |
| E0149 | Not listed | Policies naming E0149 | |
| E0163 | Not listed | Policies naming E0163 | |
| E0165 | Not listed | Policies naming E0165 | |
| E0167 | Not listed | Policies naming E0167 | |
| E0168 | Not listed | Policies naming E0168 | |
| E0170 | Not listed | Policies naming E0170 | |
| E0171 | Not listed | Policies naming E0171 | |
| E0250 | Not listed | Policies naming E0250 | |
| E0251 | Not listed | Policies naming E0251 | |
| E0255 | Not listed | Policies naming E0255 |
And 151 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