Anthem Blue Cross and Blue Shield Virginia policy
Medicare Advantage 2017 Precertification Requirements
Medicare Advantage 2017 Precertification Requirements is a public Anthem Blue Cross and Blue Shield Virginia policy (effective Jan 1, 2017). It lists 132 CPT or HCPCS codes, 95 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) ↗
- Effective
- Jan 1, 2017
- States
- CA, CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, VA, WI
- 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 |
|---|---|---|---|
| A9699 | Not listed | Policies naming A9699 | |
| C9137 | Not listed | Policies naming C9137 | |
| C9138 | Not listed | Policies naming C9138 | |
| C9257 | On the list | Injection, bevacizumab, 0.25 mg | Policies naming C9257 |
| C9473 | Not listed | Policies naming C9473 | |
| C9476 | Not listed | Policies naming C9476 | |
| C9477 | Not listed | Policies naming C9477 | |
| 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 |
| J0135 | Not listed | Policies naming J0135 | |
| J0178 | On the list | Injection, aflibercept, 1 mg | Policies naming J0178 |
| J0202 | On the list | Injection, alemtuzumab, 1 mg | Policies naming J0202 |
| J0485 | On the list | Injection, belatacept, 1 mg | Policies naming J0485 |
| J0490 | On the list | Injection, belimumab, 10 mg | Policies naming J0490 |
| J0585 | On the list | Injection, Onabotulinumtoxina, 1 Unit | Policies naming J0585 |
| J0586 | On the list | Injection, Abobotulinumtoxina, 5 Units | Policies naming J0586 |
| J0587 | On the list | Injection, Rimabotulinumtoxinb, 100 Units | Policies naming J0587 |
| J0588 | On the list | Injection, incobotulinumtoxinA, 1 unit | Policies naming J0588 |
| J0881 | On the list | Injection, darbepoetin alfa, 1 mcg (non-ESRD use) | Policies naming J0881 |
| J0885 | On the list | Injection, epoetin alfa, (for non-ESRD use), 1000 units | Policies naming J0885 |
| J0897 | On the list | Injection, denosumab, 1 mg | Policies naming J0897 |
| J1300 | Not listed | Policies naming J1300 | |
| J1325 | On the list | Epoprostenol Injection | Policies naming J1325 |
| J1438 | On the list | Etanercept Injection | Policies naming J1438 |
| J1442 | On the list | 5G-CSFexcludes biosimilars, 1 microgram | Policies naming J1442 |
| J1447 | On the list | Injection, tbo-filgrastim, 1 microgram | Policies naming J1447 |
| J1453 | Not listed | Policies naming J1453 | |
| J1459 | On the list | Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg | Policies naming J1459 |
| J1556 | On the list | Injection, immune globulin (bivigam), 500 mg | Policies naming J1556 |
| J1557 | On the list | Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg | Policies naming J1557 |
| J1559 | On the list | Injection, immune globulin (hizentra), 100 mg | Policies naming J1559 |
| J1561 | On the list | Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg | Policies naming J1561 |
| J1566 | On the list | Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg | Policies naming J1566 |
| J1568 | On the list | Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. | Policies naming J1568 |
| J1569 | On the list | Injection, immune globulin, (gammagard liquid/gammagard liquid erc), 500 mg | Policies naming J1569 |
| J1572 | On the list | Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg | Policies naming J1572 |
| J1575 | On the list | Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin | Policies naming J1575 |
| J1602 | On the list | Injection, golimumab, 1 mg, for intravenous use | Policies naming J1602 |
| J1740 | Not listed | Policies naming J1740 | |
| J1745 | On the list | Injection, infliximab, excludes biosimilar, 10 mg | Policies naming J1745 |
| J1950 | Not listed | Policies naming J1950 | |
| J2278 | On the list | Injection, ziconotide, 1 mcg | Policies naming J2278 |
| J2323 | On the list | Imjection, natalizumab, 1 mg | Policies naming J2323 |
| J2353 | On the list | Injection, octreotide, depot form for intramuscular injection, 1 mg | Policies naming J2353 |
| J2354 | On the list | Injection, octreotide, non-depot form for subcutaneous or intravenous | Policies naming J2354 |
| J2355 | Not listed | Policies naming J2355 | |
| J2357 | On the list | Omalizumab injection | Policies naming J2357 |
| J2469 | Not listed | Policies naming J2469 | |
| J2503 | Not listed | Policies naming J2503 | |
| J2505 | Not listed | Policies naming J2505 | |
| J2507 | On the list | Injection, pegloticase, 1 mg | Policies naming J2507 |
| J2778 | On the list | Injection, ranibizumab, 0.1 mg | Policies naming J2778 |
| J2796 | Not listed | Policies naming J2796 | |
| J2820 | On the list | Sargramostim Injection | Policies naming J2820 |
| J2860 | Not listed | Policies naming J2860 | |
| J2941 | On the list | Injection, somatropin, 1 mg | Policies naming J2941 |
| J3262 | On the list | Injection, tocilizumab, 1 mg | Policies naming J3262 |
| J3285 | On the list | Injection, treprostinil, 1 mg | Policies naming J3285 |
| J3380 | On the list | Injection, vedolizumab, IV, 1 mg | Policies naming J3380 |
| J3489 | On the list | Injection, zoledronic acid, 1 mg | Policies naming J3489 |
| J3490 | Not listed | Policies naming J3490 | |
| J3590 | Not listed | Policies naming J3590 | |
| J7178 | On the list | Injection, human fibrinogen concentrate, not otherwise specified, 1 mg | Policies naming J7178 |
| J7180 | On the list | Injection, factor XIII (antihemophilic factor, human), 1 IU | Policies naming J7180 |
| J7181 | On the list | Injection, factor xiii a-subunit, (recombinant), per iu | Policies naming J7181 |
| J7182 | On the list | Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu | Policies naming J7182 |
| J7183 | On the list | Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCo | Policies naming J7183 |
| J7185 | On the list | Injection, Factor Viii (Antihemophilic Factor, Recombinant) (Xyntha), Per I.U. | Policies naming J7185 |
| J7186 | On the list | Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per factor VIII i.u. | Policies naming J7186 |
| J7187 | On the list | Injection, von Willebrand factor complex (Humate-P), per IU vWF-RC0 | Policies naming J7187 |
| J7188 | On the list | Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. | Policies naming J7188 |
| J7189 | On the list | Factor VIIa (antihemophilic Factor, recombinant), per 1 mcg | Policies naming J7189 |
| J7190 | On the list | Factor Viii | Policies naming J7190 |
| J7191 | On the list | Factor Viii (Porcine) | Policies naming J7191 |
| J7192 | On the list | Factor Viii (Antihemophilic Factor, Recombinant) Per I.U., Not Otherwise Specified | Policies naming J7192 |
| J7193 | On the list | Factor IX (antihemophilic factor, purified, non-recombinant) per IU | Policies naming J7193 |
| J7194 | On the list | Factor Ix Complex | Policies naming J7194 |
| J7195 | On the list | Factor IX (antihemophilic factor, recombinant) per IU | Policies naming J7195 |
| J7198 | On the list | Anti-Inhibitor | Policies naming J7198 |
| J7199 | Not listed | Policies naming J7199 | |
| J7200 | On the list | Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu | Policies naming J7200 |
| J7201 | On the list | Injection, factor IX, Fc fusion protein, (recombinant), Alprolix, 1 IU | Policies naming J7201 |
| J7205 | On the list | Injection, factor viii fc fusion (recombinant), per iu | Policies naming J7205 |
| J7311 | On the list | Injection, fluocinolone acetonide, intravitreal implant (Retisert), 0.01 mg | Policies naming J7311 |
| J7312 | On the list | Injection, dexamethasone, intravitreal implant, 0.1 mg | Policies naming J7312 |
| J7313 | On the list | Injection, fluocinolone acetonide, intravitreal implant (Iluvien), 0.01 mg | Policies naming J7313 |
| J7316 | Not listed | Policies naming J7316 | |
| J7321 | Not listed | Policies naming J7321 | |
| J7323 | Not listed | Policies naming J7323 | |
| J7324 | Not listed | Policies naming J7324 | |
| J7325 | Not listed | Policies naming J7325 | |
| J7327 | Not listed | Policies naming J7327 | |
| J7328 | Not listed | Policies naming J7328 | |
| J7340 | On the list | Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml | Policies naming J7340 |
| J7686 | On the list | Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, 1.74 mg | Policies naming J7686 |
| J9010 | Not listed | Policies naming J9010 | |
| J9015 | On the list | Injection, aldesleukin, per single use vial | Policies naming J9015 |
| J9035 | On the list | Bevacizumab injection | Policies naming J9035 |
| J9039 | On the list | Injection, blinatumomab, 1 microgram | Policies naming J9039 |
| J9042 | On the list | Injection, brentuximab vedotin, 1 mg | Policies naming J9042 |
| J9043 | On the list | Injection, cabazitaxel, 1 mg | Policies naming J9043 |
| J9047 | On the list | Injection, carfilzomib, 1 mg | Policies naming J9047 |
| J9055 | On the list | Cetuximab injection | Policies naming J9055 |
| J9155 | Not listed | Policies naming J9155 | |
| J9179 | On the list | Injection, eribulin mesylate, 0.1 mg | Policies naming J9179 |
| J9202 | On the list | Goserelin Acetate Implant | Policies naming J9202 |
| J9207 | On the list | Injection, ixabepilone, 1 mg | Policies naming J9207 |
| J9217 | On the list | Leuprolide Acetate Suspnsion | Policies naming J9217 |
| J9218 | Not listed | Policies naming J9218 | |
| J9219 | Not listed | Policies naming J9219 | |
| J9228 | On the list | Injection, ipilimumab, 1 mg | Policies naming J9228 |
| J9262 | On the list | Injection, omacetaxine mepesuccinate, 0.01 mg | Policies naming J9262 |
| J9264 | On the list | Injection, paclitaxel protein-bound particles, 1 mg | Policies naming J9264 |
| J9266 | On the list | Injection, pegaspargase, per single dose vial | Policies naming J9266 |
| J9271 | On the list | Injection, pembrolizumab, 1 mg | Policies naming J9271 |
| J9299 | On the list | Injection, nivolumab, 1 mg | Policies naming J9299 |
| J9301 | On the list | Injection, obinutuzumab, 10 mg | Policies naming J9301 |
| J9302 | On the list | Injection, ofatumumab, 10 mg | Policies naming J9302 |
| J9303 | On the list | Injection, panitumumab, 10 mg | Policies naming J9303 |
| J9305 | On the list | Injection, pemetrexed, NOS,10 mg | Policies naming J9305 |
| J9306 | On the list | Injection, pertuzumab, 1 mg | Policies naming J9306 |
| J9308 | On the list | Injection, ramucirumab, 5 mg | Policies naming J9308 |
| J9310 | Not listed | Policies naming J9310 | |
| J9315 | Not listed | Policies naming J9315 | |
| J9351 | Not listed | Policies naming J9351 | |
| J9354 | On the list | Injection, ado-trastuzumab emtansine, 1 mg | Policies naming J9354 |
| J9355 | Not listed | Policies naming J9355 | |
| J9400 | On the list | Injection, ziv-aflibercept, 1 mg | Policies naming J9400 |
| Q0515 | Not listed | Policies naming Q0515 | |
| Q2043 | On the list | Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion | Policies naming Q2043 |
| Q4074 | On the list | Iloprost, Inhalation Solution, Fda-Approved Final Product, Non-Compounded, Administered Through Dme, Unit Dose Form, Up | Policies naming Q4074 |
| Q5101 | On the list | Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram | Policies naming Q5101 |
| Q9980 | Not listed | Policies naming Q9980 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list