Anthem Blue Cross and Blue Shield Virginia prior authorization code reference, page 78

Source code lookup

Each row links an imported source code to its service or category label. Check the original document for the complete plan scope, review type and qualifications.

Source code index

Imported source codes and labels; verify the complete review requirements in the original document
Code	Description	Source
S9480	Intensive Outpatient Psychia	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9490	Home infusion therapy, corticosteroid infusion; administrative services, professional pharmacy services, care coordinati	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9494	Home infusion therapy, antibiotic, antiviral, or antifungal therapy (do not use with home infusion codes for hourly dosi	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9497	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every three hours	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 81 Original policy
S9500	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
S9501	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
S9502	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
S9503	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every six hours	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
S9504	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every four hours	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
S9542	Home injectable therapy; not otherwise classified	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
S9810	Home therapy; professional pharmacy service for provision of infusion, specialty drug administration, and/or disease sta	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
S9960	Ambulance service, conventional air services, nonemergency transport, one way (fixed wing)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
S9961	Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
T1001	Nursing assessment/evaluation	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
T1002	RN services, up to 15 minutes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
T1003	LPN/LVN services, up to 15 minutes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
T1004	Services of a qualified nursing aide, up to 15 minutes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
T1021	Home Health Aide Or Certified Nurse Assistant, Per Visit	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
T1022	Contracted Home Health Agency Services, All Services Provided Under Co	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
T2036	Therapeutic camping, overnight, waiver; each session	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
T2037	Therapeutic camping, day, waiver; each session	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
V2787	Astigmatism correcting function of intraocular lens	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
V2788	Presbyopia correcting function of intraocular lens	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
V2790	Amniotic Membrane	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
V5095	Semi-Implantable Middle Ear Hearing Prosthesis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
V5298	Hearing Aid, Not Otherwise Classified	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
V5362	Speech Screening	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
V5363	Language Screening	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
V5364	Dysphagia Screening	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 82 Original policy
0417T	Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values	Virginia PPO standard precertification/prior authorization requirements, Pg 6 Original policy
0417U	Rare diseases (constitutional/heritable disorders), whole mitochondrial genome sequence with heteroplasmy detection and deletion analysis, nuclear-encoded mitochondrial gene a	Virginia PPO standard precertification/prior authorization requirements, Pg 6 Original policy
0418T	Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable cardiac contr	Virginia PPO standard precertification/prior authorization requirements, Pg 6 Original policy
0419U	Neuropsychiatry (eg, depression, anxiety), genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotype	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0420U	Oncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR (ddPCR) analysis	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0422U	Oncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatmen	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0424U	Oncology (prostate), exosome-based analysis of 53 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT-qPCR), urine, reported as	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0425U	Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis, each comparator genome (eg, parents, siblings)	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0426U	Genome (eg, unexplained constitutional or heritable disorder or syndrome), ultra-rapid sequence analysis	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0433U	Oncology (prostate), 5 DNA regulatory markers by quantitative PCR, whole blood, algorithm, including prostate-specific antigen, reported as likelihood of cancer	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0434U	Drug metabolism (adverse drug reactions and drug response), genomic analysis panel, variant analysis of 25 genes with reported phenotypes	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0435U	Oncology, chemotherapeutic drug cytotoxicity assay of cancer stem cells (CSCs), from cultured CSCs and primary tumor cells, categorical drug response reported based on cytotox	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0437U	Psychiatry (anxiety disorders), mRNA, gene expression profiling by RNA sequencing of 15 biomarkers, whole blood, algorithm reported as predictive risk score	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0438U	Drug metabolism (adverse drug reactions and drug response), buccal specimen, gene-drug interactions, variant analysis of 33 genes, including deletion/duplication analysis of C	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0439U	Cardiology (coronary heart disease [CHD]), DNA, analysis of 5 single-nucleotide polymorphisms (SNPs) (rs11716050 [LOC105376934], rs6560711 [WDR37], rs3735222 [SCIN/LOC10798676	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0440T	Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0440U	Cardiology (coronary heart disease [CHD]), DNA, analysis of 10 single-nucleotide polymorphisms (SNPs) (rs710987 [LINC010019], rs1333048 [CDKN2B-AS1], rs12129789 [KCND3], rs942	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0441T	Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0442T	Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve)	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0444U	Oncology (solid organ neoplasia), targeted genomic sequence analysis panel of 361 genes, interrogation for gene fusions, translocations, or other rearrangements, using DNA fro	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy
0449T	Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device	Virginia PPO standard precertification/prior authorization requirements, Pg 7 Original policy

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