Anthem Blue Cross and Blue Shield Virginia policy
Virginia Professional Provider Manual
Virginia Professional Provider Manual is a public Anthem Blue Cross and Blue Shield Virginia policy (policy VABCBS-CM-PM-086207-25, effective Dec 1, 2025). It lists 139 CPT or HCPCS codes, 80 of them on the Anthem Blue Cross and Blue Shield Virginia prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- VABCBS-CM-PM-086207-25
- Effective
- Dec 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 |
|---|---|---|---|
| 00001 | Not listed | Policies naming 00001 | |
| 0240U | Not listed | Policies naming 0240U | |
| 0241U | Not listed | Policies naming 0241U | |
| 0362T | On the list | Behavior identification supporting assessment, each 15 minutes of technicians' time face-to- face with a patient, requiring the following components: administration by the phys | Policies naming 0362T |
| 0373T | On the list | Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by | Policies naming 0373T |
| 12345 | Not listed | Policies naming 12345 | |
| 23279 | Not listed | Policies naming 23279 | |
| 23407 | Not listed | Policies naming 23407 | |
| 23466 | On the list | Capsulorrhaphy, Glenohumeral Joint, Any Type Multi-Directional Instability | Policies naming 23466 |
| 27401 | Not listed | Policies naming 27401 | |
| 30308 | Not listed | Policies naming 30308 | |
| 30348 | Not listed | Policies naming 30348 | |
| 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 | |
| 61010 | Not listed | Policies naming 61010 | |
| 73651 | Not listed | Policies naming 73651 | |
| 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 |
| 80051 | On the list | Electrolyte Panel | Policies naming 80051 |
| 80061 | On the list | Lipid Panel | Policies naming 80061 |
| 80069 | On the list | Renal function panel This panel must include the following: Albumin (82040) Calcium, total (82310) Carbon dioxide (bicar | Policies naming 80069 |
| 80178 | On the list | Assay Of Lithium | Policies naming 80178 |
| 80305 | Not listed | Policies naming 80305 | |
| 81000 | On the list | Urinalysis, Dip Stick/Tablet Reagent; Non-Automated W/Microscopy | Policies naming 81000 |
| 81001 | On the list | Urinalysis, Dip Stick/Tablet Reagent; Automated W/O Microscopy | Policies naming 81001 |
| 81002 | On the list | Urinalysis, Dip Stick/Tablet Reagent; Non-Automated, W/O Microscopy | Policies naming 81002 |
| 81003 | On the list | Urinalysis, Dip Stick/Tablet Reagent; Automated, W/O Microscopy | Policies naming 81003 |
| 81015 | On the list | Urinalysis; Microscopic Only | Policies naming 81015 |
| 81025 | On the list | Urine Pregnancy Test, Visual Color Comparison Methods | Policies naming 81025 |
| 82010 | On the list | Ketone body(s) (eg, acetone, acetoacetic acid, beta-hydroxybutyrate); quantitative | Policies naming 82010 |
| 82040 | On the list | Albumin; serum, plasma or whole blood | Policies naming 82040 |
| 82044 | On the list | Albumin; urine (eg, microalbumin), semiquantitative (eg, reagent strip assay) | Policies naming 82044 |
| 82120 | On the list | Amines, Vaginal Fluid, Qualitative | Policies naming 82120 |
| 82150 | On the list | Amylase | Policies naming 82150 |
| 82247 | On the list | Bilirubin; Total | Policies naming 82247 |
| 82248 | On the list | Bilirubin; Direct | Policies naming 82248 |
| 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 |
| 82271 | On the list | Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources | Policies naming 82271 |
| 82272 | On the list | Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for o | Policies naming 82272 |
| 82465 | On the list | Cholesterol, Serum/Whole Blood, Total | Policies naming 82465 |
| 82550 | On the list | Creatine Kinase (Ck), (Cpk); Total | Policies naming 82550 |
| 82570 | On the list | Creatinine; Other Source | Policies naming 82570 |
| 82679 | On the list | Estrone | Policies naming 82679 |
| 82948 | Not listed | Policies naming 82948 | |
| 82950 | Not listed | Policies naming 82950 | |
| 82951 | Not listed | Policies naming 82951 | |
| 82952 | Not listed | Policies naming 82952 | |
| 82962 | Not listed | Policies naming 82962 | |
| 82977 | Not listed | Policies naming 82977 | |
| 82985 | Not listed | Policies naming 82985 | |
| 83001 | Not listed | Policies naming 83001 | |
| 83002 | Not listed | Policies naming 83002 | |
| 83014 | Not listed | Policies naming 83014 | |
| 83026 | Not listed | Policies naming 83026 | |
| 83036 | Not listed | Policies naming 83036 | |
| 83037 | Not listed | Policies naming 83037 | |
| 83516 | On the list | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitativ | Policies naming 83516 |
| 83605 | Not listed | Policies naming 83605 | |
| 83655 | Not listed | Policies naming 83655 | |
| 83718 | Not listed | Policies naming 83718 | |
| 83721 | Not listed | Policies naming 83721 | |
| 83861 | Not listed | Policies naming 83861 | |
| 83880 | On the list | Natriuretic Peptide | Policies naming 83880 |
| 84075 | On the list | Phosphatase, Alkaline | Policies naming 84075 |
| 84155 | On the list | Protein, total, except by refractometry; serum, plasma or whole blood | Policies naming 84155 |
| 84443 | On the list | Thyroid Stimulating Hormone (Tsh) | Policies naming 84443 |
| 84450 | On the list | Transferase; Aspartate Amino (Ast) (Sgot) | Policies naming 84450 |
| 84460 | On the list | Transferase; Alanine Amino (Alt) (Sgpt) | Policies naming 84460 |
| 84478 | On the list | Triglycerides | Policies naming 84478 |
| 84550 | On the list | Uric Acid; Blood | Policies naming 84550 |
| 84703 | On the list | Gonadotropin, Chorionic (Hcg); Qualitative | Policies naming 84703 |
| 84830 | On the list | Ovulation Tests, Visual Color Comparison Methods, Human Luteinizing Hormone | Policies naming 84830 |
| 85013 | On the list | Blood Count; Spun Microhematocrit | Policies naming 85013 |
| 85014 | On the list | Blood Count; Hematocrit | Policies naming 85014 |
| 85018 | On the list | Blood Count; Hemoglobin | Policies naming 85018 |
| 85025 | On the list | Blood Count; Complete Cbc, Automated (Hgb, Hct, Rbc, Wbc, & Platelet) & Automated Differential Wbc | Policies naming 85025 |
| 85027 | On the list | Blood Count; Complete Cbc, Automated (Hgb, Hct, Rbc, Wbc, & Platelet) | Policies naming 85027 |
| 85610 | On the list | Prothrombin Time | Policies naming 85610 |
| 85651 | On the list | Sedimentation Rate, Erythrocyte; Non-Automated | Policies naming 85651 |
| 85652 | On the list | Sedimentation Rate, Erythrocyte; Automated | Policies naming 85652 |
| 86140 | On the list | C-Reactive Protein | Policies naming 86140 |
| 86294 | On the list | Immunoassay For Tumor Antigen, Qualitative/Semiquantitative | Policies naming 86294 |
| 86308 | On the list | Heterophile Antibodies; Screening | Policies naming 86308 |
| 86318 | On the list | Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip) | Policies naming 86318 |
| 86328 | On the list | Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS | Policies naming 86328 |
| 86408 | Not listed | Policies naming 86408 | |
| 86409 | Not listed | Policies naming 86409 | |
| 86413 | Not listed | Policies naming 86413 | |
| 86580 | On the list | Skin Test; Tuberculosis, Intradermal | Policies naming 86580 |
| 86701 | On the list | Antibody; Hiv-1 | Policies naming 86701 |
| 86769 | On the list | Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) | Policies naming 86769 |
| 86780 | On the list | Antibody; Treponema pallidum | Policies naming 86780 |
| 86803 | On the list | Hepatitis C Antibody | Policies naming 86803 |
| 87077 | On the list | Culture, Bacterial; Aerobic Isolate, Add'l Methods Required For Definitive Id, Ea Isolate | Policies naming 87077 |
| 87081 | On the list | Culture, Presumptive, Pathogenic Organisms, Screening Only | Policies naming 87081 |
| 87210 | On the list | Smear, Primary Source W/Interpretation; Wet Mount, For Infectious Agents | Policies naming 87210 |
| 87220 | On the list | Tissue Exam By Koh Slide Of Samples From Skin/Hair/Nails, Fungi/Ectoparasite Ova/Mites | Policies naming 87220 |
| 87426 | Not listed | Policies naming 87426 | |
| 87428 | Not listed | Policies naming 87428 | |
| 87449 | On the list | Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunoch | Policies naming 87449 |
| 87502 | On the list | Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multip | Policies naming 87502 |
| 87631 | On the list | Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syn | Policies naming 87631 |
| 87633 | On the list | Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syn | Policies naming 87633 |
| 87634 | On the list | Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe technique | Policies naming 87634 |
| 87635 | On the list | Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe techniq | Policies naming 87635 |
| 87636 | Not listed | Policies naming 87636 | |
| 87637 | Not listed | Policies naming 87637 | |
| 87651 | On the list | Infectious Agent, Nucleic Acid (Dna/Rna); Streptococcus Group A, Amplified Probe | Policies naming 87651 |
| 87804 | On the list | Infectious agent antigen detection by immunoassay with direct optical | Policies naming 87804 |
| 87807 | On the list | Infectious agent antigen detection by immunoassay with direct optical | Policies naming 87807 |
| 87808 | On the list | Infectious agent antigen detection by immunoassay with direct optical | Policies naming 87808 |
| 87809 | On the list | Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; adenovirus | Policies naming 87809 |
| 87811 | Not listed | Policies naming 87811 | |
| 87880 | On the list | Infectious agent antigen detection by immunoassay with direct optical | Policies naming 87880 |
| 87905 | On the list | Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid) | Policies naming 87905 |
| 90702 | Not listed | Policies naming 90702 | |
| 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 | |
| 96101 | Not listed | Policies naming 96101 | |
| 96119 | Not listed | Policies naming 96119 | |
| 97151 | On the list | Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care | Policies naming 97151 |
| 97158 | On the list | Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each | Policies naming 97158 |
| C9803 | Not listed | Policies naming C9803 | |
| G2023 | Not listed | Policies naming G2023 | |
| G2024 | Not listed | Policies naming G2024 | |
| H0023 | Not listed | Policies naming H0023 | |
| J0610 | Not listed | Policies naming J0610 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list