Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list, page 76

CPT code lookup

Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.

Prior authorization codes

Prior authorization codes
Code	Description	Source
Q5133	Injection, tocilizumab-bavi (Tofidence), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5134	Injection, natalizumab-sztn (Tyruko), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5135	Injection, tocilizumab-aazg (tyenne), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5136	Injection, denosumab-bbdz (jubbonti/wyost), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5137	Injection, ustekinumab-auub (Wezlana), biosimilar, SC, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5138	Injection, ustekinumab-auub (Wezlana), biosimilar, IV, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5146	Injection, trastuzumab-strf (hercessi), biosimilar, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5148	Injection, filgrastim-txid (Nypozi), biosimilar, 1 mcg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5156	Injection, tocilizumab-anoh (Avtozma), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5157	Injection, denosumab-bmwo (Stoboclo/Osenvelt), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5158	Injection, denosumab-bnht (Bomyntra/Conexxence), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5159	Injection, denosumab-dssb (Ospomyv/Xbryk), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5160	Injection, bevacizumab-nwgd (jobevne), biosimilar, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5161	Injection, denosumab-kyqq (aukelso/bosaya), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5162	Injection, denosumab-nxxp (bildyos/bilprevda), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5165	Injection, denosumab-mobz (oziltus), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5166	Injection, denosumab-desu (osvyrti/jubereq), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5167	Injection, denosumab-qbde (enoby/xtrenbo), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5169	Injection, pegfilgrastim-unne (armlupeg), biosimilar, 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
Q5171	Injection, denosumab-mobz (boncresa), biosimilar, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S0201	Partial Hospitalization Services, Less Than 24 Hours, Per Diem	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S0353	Treatment planning and care coordination management for cancer initial treatment	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S0354	Treatment planning and care coordination management for cancer established patient with a change of regimen	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S1091	Stent, non-coronary, temporary, with delivery system (propel)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2053	Transplantation Of Small Int	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2054	Transplantation Of Multivisc	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2055	Harvesting Of Donor Multivis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2060	Lobar Lung Transplantation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2061	Donor Lobectomy (Lung)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2065	Simultaneous pancreas kidney transplantation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2066	Breast reconstruction with gluteal artery perforator (GAP) flap, including	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2067	Breast reconstruction of a single breast with "stacked" deep inferior	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2068	Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SI	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2080	Laser-assisted uvulopalatoplasty (LAUP)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2102	Islet Cell Tissue Transplant	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2103	Adrenal Tissue Transplant	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2112	Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2117	Arthroereisis, subtalar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2118	Metal-on-metal total hip resurfacing including acetabular and femoral components	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2142	Cord Blood-Derived Stem-Cell	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2150	Bone marrow or blood-derived peripheral stem cell harvesting and transplantation, allogenic or autologous, including phe	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2202	Echosclerotherapy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2230	Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2260	Induced abortion, 17 TO 24 weeks	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2265	Induced abortion, 25 TO 28 weeks	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2266	Induced abortion, 29 TO 31 weeks	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2267	Induced abortion, 32 weeks or greater	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2300	Arthroscopy, Shoulder, Surgi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 80 Original policy
S2342	Nasal endoscopy for post-operative debridement following functional endoscopic sinus surgery, nasal and/or sinus cavity(	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S2348	Decompress disc RF lumbar	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

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