Anthem Blue Cross and Blue Shield Virginia prior authorization code reference, page 80

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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
0516T	Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performe	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0516U	Drug metabolism, whole blood, pharmacogenomic genotyping of 40 genes and CYP2D6 copy number variant analysis, reported as metabolizer status	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0517T	Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performe	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0519T	Removal and replacement of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; both components (batter	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0520T	Removal and replacement of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; battery component only	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0521U	Rheumatoid factor IgA and IgM, cyclic citrullinated peptide (CCP) antibodies, and scavenger receptor A (SR-A) by immunoassay, blood	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0523U	Oncology (solid tumor), DNA, qualitative, next-generation sequencing (NGS) of singlenucleotide variants (SNV) and insertion/deletions in 22 genes utilizing formalin-fixed par	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0524T	Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0524U	Obstetrics (preeclampsia), sFlt1/PlGF ratio, immunoassay, utilizing serum or plasma, reported as a value	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0525T	Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpr	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0526T	Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpr	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0527T	Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpr	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0528T	Programming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and report	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0529T	Interrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and report	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0529U	Hematology (venous thromboembolism [VTE]), genome-wide single-nucleotide polymorphism variants, including F2 and F5 gene analysis, and Leiden variant, by microarray analysis	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0530T	Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; complete system (electrode and implantable monitor)	Virginia PPO standard precertification/prior authorization requirements, Pg 8 Original policy
0530U	Oncology (pan-solid tumor), ctDNA, utilizing plasma, nextgeneration sequencing (NGS) of 77 genes, 8 fusions, microsatellite instability, and tumor mutation burden, interpreta	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0531T	Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; electrode only	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0532T	Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; implantable monitor only	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0532U	Rare diseases (constitutional disease/hereditary disorders), rapid whole genome and mitochondrial DNA sequencing for single-nucleotide variants, insertions/deletions, copy num	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0533U	Drug metabolism (adverse drug reactions and drug response), genotyping of 16 genes (ie, ABCG2, CYP2B6, CYP2C9, CYP2C19, CYP2C, CYP2D6, CYP3A5, CYP4F2, DPYD, G6PD, GGCX, NUDT15	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0534U	Oncology (prostate), microRNA, single-nucleotide polymorphisms (SNPs) analysis by RT-PCR of 32 variants, using buccal swab, algorithm reported as a risk score	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0536U	Red blood cell antigen (fetal RhD), PCR analysis of exon 4 of RHD gene and housekeeping control gene GAPDH from whole blood in pregnant individuals at 10+ weeks gestation know	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0537U	Oncology (colorectal cancer), analysis of cell-free DNA for epigenomic patterns, next- generation sequencing, >2500 differentially methylated regions (DMRs), plasma, algorithm	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0538U	Oncology (solid tumor), next-generation targeted sequencing analysis, formalin-fixed paraffin- embedded (FFPE) tumor tissue, DNA analysis of 600 genes, interrogation for single	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0539U	Oncology (solid tumor), cell-free circulating tumor DNA (ctDNA), 152 genes, next-generation sequencing, interrogation for single-nucleotide variants, insertions/deletions, gen	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0540U	Transplantation medicine, quantification of donor-derived cell-free DNA using next-generation sequencing analysis of plasma, reported as percentage of donor-derived cell-free	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0543U	Oncology (solid tumor), next-generation sequencing of DNA from formalin-fixed paraffin- embedded (FFPE) tissue of 517 genes, interrogation for single-nucleotide variants, multi	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0544T	Transcatheter mitral valve annulus reconstruction, with implantation of adjustable annulus reconstruction device, percutaneous approach including transseptal puncture	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0545T	Transcatheter tricuspid valve annulus reconstruction with implantation of adjustable annulus reconstruction device, percutaneous approach	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0546T	Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0549U	Oncology (urothelial), DNA, quantitative methylated real-time PCR of TRNA-Cys, SIM2, and NKX1-1, using urine, diagnostic algorithm reported as a probability index for bladder	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0552T	Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0552U	Reproductive medicine (preimplantation genetic assessment), analysis for known genetic disorders from trophectoderm biopsy, linkage analysis of disease-causing locus, and when	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0553U	Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrang	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0554U	Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, a	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0555U	Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrang	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0560U	Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell-free DNA, whole blood and tumor tissue, baseline assessment for design and construction of a persona	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0561U	Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell-free DNA, whole blood, subsequent assessment with comparison to initial assessment to evaluate for M	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0562U	Oncology (solid tumor), targeted genomic sequence analysis, 33 genes, detection of single- nucleotide variants (SNVs), insertions and deletions, copy-number amplifications, and	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0563T	Evacuation of meibomian glands, using heat delivered through wearable, open-eye eyelid treatment devices and manual gland expression, bilateral	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0565T	Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0565U	Oncology (hepatocellular carcinoma), next-generation sequencing methylation pattern assay to detect 6626 epigenetic alterations, cell-free DNA, plasma, algorithm reported as c	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0566T	Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound gu	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0566U	Oncology (lung), qPCR-based analysis of 13 differentially methylated regions (CCDC181, HOXA7, LRRC8A, MARCHF11, MIR129-2, NCOR2, PANTR1, PRKCB, SLC9A3, TBR1_2, TRAP1, VWC2, ZN	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0567U	Rare diseases (constitutional/heritable disorders), whole-genome sequence analysis combination of short and long reads, for single-nucleotide variants, insertions/deletions an	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0569T	Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0569U	Oncology (solid tumor), next-generation sequencing analysis of tumor methylation markers (>20000 differentially methylated regions) present in cell-free circulating tumor DNA	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0571U	Oncology (solid tumor), DNA (80 genes) and RNA (10 genes), by next-generation sequencing, plasma, including single-nucleotide variants, insertions/deletions, copy-number alter	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy
0580T	Removal of substernal implantable defibrillator pulse generator only	Virginia PPO standard precertification/prior authorization requirements, Pg 9 Original policy

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