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 (effective Dec 1, 2023). It lists 141 CPT or HCPCS codes, 79 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
- Dec 1, 2023
- 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 | |
| 0202U | Not listed | Policies naming 0202U | |
| 0223U | Not listed | Policies naming 0223U | |
| 0224U | Not listed | Policies naming 0224U | |
| 0225U | Not listed | Policies naming 0225U | |
| 0226U | Not listed | Policies naming 0226U | |
| 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 | |
| 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 | |
| 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