Anthem Blue Cross and Blue Shield Virginia policy
VIRGINIA FACILITY PROVIDER MANUAL
VIRGINIA FACILITY PROVIDER MANUAL is a public Anthem Blue Cross and Blue Shield Virginia policy (effective Aug 23, 2019). It lists 58 CPT or HCPCS codes, 13 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
- Aug 23, 2019
- 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 |
|---|---|---|---|
| 0359T | Not listed | Policies naming 0359T | |
| 0374T | Not listed | Policies naming 0374T | |
| 12345 | Not listed | Policies naming 12345 | |
| 23230 | Not listed | Policies naming 23230 | |
| 23279 | Not listed | Policies naming 23279 | |
| 27401 | Not listed | Policies naming 27401 | |
| 36415 | Not listed | Policies naming 36415 | |
| 36416 | Not listed | Policies naming 36416 | |
| 44135 | On the list | Intestinal Allotransplantation; From Cadaver Donor | Policies naming 44135 |
| 44193 | Not listed | Policies naming 44193 | |
| 59400 | Not listed | Policies naming 59400 | |
| 59410 | Not listed | Policies naming 59410 | |
| 59510 | Not listed | Policies naming 59510 | |
| 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 | |
| 60197 | Not listed | Policies naming 60197 | |
| 73651 | Not listed | Policies naming 73651 | |
| 90801 | Not listed | Policies naming 90801 | |
| 90867 | On the list | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management | Policies naming 90867 |
| 90869 | On the list | Therapeutic Repetitive Transcranial Magnetic Stimulation (Tms) Treatment; Subsequent Motor Threshold Re-Determination With Delivery And Management | Policies naming 90869 |
| 90899 | Not listed | Policies naming 90899 | |
| 94760 | Not listed | Policies naming 94760 | |
| 94761 | Not listed | Policies naming 94761 | |
| 94762 | Not listed | Policies naming 94762 | |
| 96365 | On the list | Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour | Policies naming 96365 |
| 96366 | Not listed | Policies naming 96366 | |
| 96368 | Not listed | Policies naming 96368 | |
| 96374 | Not listed | Policies naming 96374 | |
| 96379 | Not listed | Policies naming 96379 | |
| 97032 | On the list | Application, Modality 1+ Areas; Electrical Stimulation (Manual), Each 15 Min | Policies naming 97032 |
| 97035 | On the list | Application, Modality To 1+ Areas; Ultrasound, Each 15 Min | Policies naming 97035 |
| 97036 | On the list | Application, Modality To 1+ Areas; Hubbard Tank, Each 15 Min | Policies naming 97036 |
| 97110 | On the list | Therapeutic Proc, 1+ Areas, Each 15 Min; Therapeutic Exercises | Policies naming 97110 |
| 97124 | On the list | Therapeutic Proc, 1+ Areas, Each 15 Min; Massage | Policies naming 97124 |
| 97140 | On the list | Manual Therapy Techniques, 1+ Regions, Each 15 Min | Policies naming 97140 |
| 97530 | On the list | Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes | Policies naming 97530 |
| 97542 | On the list | Wheelchair management (eg, assessment, fitting, training), each 15 minutes | Policies naming 97542 |
| 97760 | On the list | Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s | Policies naming 97760 |
| 97762 | Not listed | Policies naming 97762 | |
| 99001 | Not listed | Policies naming 99001 | |
| 99281 | Not listed | Policies naming 99281 | |
| 99282 | Not listed | Policies naming 99282 | |
| 99283 | Not listed | Policies naming 99283 | |
| 99284 | Not listed | Policies naming 99284 | |
| 99285 | Not listed | Policies naming 99285 | |
| G0001 | Not listed | Policies naming G0001 | |
| G0380 | Not listed | Policies naming G0380 | |
| G0381 | Not listed | Policies naming G0381 | |
| G0382 | Not listed | Policies naming G0382 | |
| G0383 | Not listed | Policies naming G0383 | |
| G0384 | Not listed | Policies naming G0384 | |
| J0610 | Not listed | Policies naming J0610 | |
| S2900 | Not listed | Policies naming S2900 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list