Anthem Blue Cross and Blue Shield Virginia prior authorization code reference, page 83

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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
0971T	Ablation, malignant breast tumor(s), percutaneous, laser, including imaging guidance when performed, unilateral	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
11920	Tattooing To Correct Color Defects; 6.0 Sq Cm/<	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
11921	Tattooing To Correct Color Defects; 6.1-20.0 Sq Cm	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
11950	Subq Injection, Filling Matl; 1 Cc/<	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
11951	Subq Injection, Filling Matl; 1.1 To 5.0 Cc	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
11952	Subq Injection, Filling Matl; 5.1 To 10.0 Cc	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
11954	Subq Injection, Filling Matl; > 10.0 Cc	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
14040	Adjacent Tissue Transfer, Forehead/Cheeks/Chin/Mouth/Neck/Axillae/Genitalia/Hands/Feet; 10 Sq Cm/<	Virginia PPO standard precertification/prior authorization requirements, Pg 12 Original policy
27412	Autologous Chondrocyte Implantation, Knee	Virginia PPO standard precertification/prior authorization requirements, Pg 18 Original policy
27415	Rep Ligaments Knee+pes Anserin Tran	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27416	Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft(s)	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27425	Lateral Retinacular Release Open	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27427	Ligamentous Reconstruction (Augmentation), Knee; Extra-Articular	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27428	Ligamentous Reconstruction (Augmentation), Knee; Intra-Articular, (Open)	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27429	Ligamentous Reconstruction (Augmentation), Knee; Intra-Articular, (Open) & Extra-Articular	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27437	Arthroplasty, Patella; W/O Prosthesis	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27438	Arthroplasty, Patella; W/Prosthesis	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27440	Arthroplasty, Knee, Tibial Plateau	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27441	Arthroplasty, Knee, Tibial Plateau; W/Debridement & Partial Synovectomy	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27442	Arthroplasty, Femoral Condyles/Tibial Plateau(S), Knee	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27446	Arthroplasty, Knee, Condyle & Plateau; Medial/Lateral Compartment	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27447	Arthroplasty, Knee, Condyle & Plateau; Medial & Lateral Compartments, W/Wo Patella Resurfacing	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27486	Revision, Total Knee Arthroplasty, W/Wo Allograft; 1 Component	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27487	Revision, Total Knee Arthroplasty; Femoral & Entire Tibial Component	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27488	Removal, Knee Prosthesis, Methylmethacrylate W/Wo Spacer Insertion	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27570	Manipulation, Knee Joint Under General Anesthesia	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27702	Arthroplasty, Ankle; W/Implant (Total Ankle)	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27703	Arthroplasty, Ankle; Revision, Total Ankle	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27704	Removal, Ankle Implant	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27860	Manipulation, Ankle Under General Anesthesia	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
27870	Arthrodesis, Ankle, Open	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28110	Ostectomy, Partial Excision, 5th Metatarsal Head (Bunionette) (Sep Proc)	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28285	Correction, Hammertoe	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28286	Correction, Cock-Up Fifth Toe, W/Plastic Skin Closure	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28289	Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28291	Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint with implant	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28292	Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with resection of proximal phalanx base, when performed, any method	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28295	Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal metatarsal osteotomy, any method	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28296	Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with distal metatarsal osteotomy, any method	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28297	Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28298	Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal phalanx osteotomy, any method	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28299	Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with double osteotomy, any method	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28306	Osteotomy, Metatarsal, W/Wo Lengthening/Shortening/Ang Correction; 1st Metatarsal	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28307	Osteotomy, Metatarsal, W/Wo Lengthening/Shortening/Ang Correction; 1st Metatarsal W/Autograft	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28308	Osteotomy, Metatarsal, W/Wo Lengthening/Shortening/Ang Correction; Not 1st Metatarsal, Each	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28310	Osteotomy, Shortening, Angular/Rotational Correction; Proximal Phalanx, 1st Toe (Sep Proc)	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28312	Osteotomy, Shortening, Angular/Rotational Correction; Other Phalanges, Any Toe	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28315	Sesamoidectomy, 1st Toe (Sep Proc)	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28446	Open osteochondral autograft, talus (includes obtaining grafts)	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
28750	Arthrodesis, Great Toe; Metatarsophalangeal Joint	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy

Sources

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