Anthem Blue Cross and Blue Shield Virginia prior authorization code reference, page 84

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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
28890	Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guida	Virginia PPO standard precertification/prior authorization requirements, Pg 19 Original policy
29800	Arthroscopy, Temporomandibular Joint, Dx W/Wo Synovial Bx (Sep Proc)	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29804	Arthroscopy, Temporomandibular Joint, Surgical	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29805	Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure)	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29806	Arthroscopy, shoulder, surgical; capsulorrhaphy	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29807	Arthroscopy, shoulder, surgical; repair of SLAP lesion	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29819	Arthroscopy, shoulder, surgical; with removal of loose body or foreign body	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29820	Arthroscopy, shoulder, surgical; synovectomy, partial	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29821	Arthroscopy, shoulder, surgical; synovectomy, complete	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29822	Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, bi	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29823	Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilag	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29824	Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29825	Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29826	Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separatel	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29827	Arthroscopy, shoulder, surgical; with rotator cuff repair	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29828	Arthroscopy, shoulder, surgical; biceps tenodesis	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29860	Arthroscopy, Hip, Dx W/Wo Synovial Bx (Sep Proc)	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29861	Arthroscopy, Hip, Surgical; W/Removal, Loose/Foreign Body	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29862	Arthroscopy, Hip, Surgical; W/Chondroplasty/Arthroplasty, &/Or Resection, Labrum	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29863	Arthroscopy, Hip, Surgical; W/Synovectomy	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s])	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29867	Arthroscopy, Knee, Surgical; Osteochondral Allograft (Eg, Mosaicplasty)	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29868	Arthroscopy, Knee, Surgical; Meniscal Transplantation (Includes Arthrotomy For Meniscal Insertion), Medial Or Lateral	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29870	Arthroscopy, Knee, Dx, W/Wo Synovial Bx (Sep Proc)	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29871	Arthroscopy, Knee, Surgical; Infection, Lavage & Drainage	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29873	Arthroscopy, Knee, Surgical; W/Lateral Release	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29874	Arthroscopy, Knee, Surgical; Removal, Loose/Fb	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29875	Arthroscopy, Knee, Surgical; Synovectomy, Limited (Sep Proc)	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29876	Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral)	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29877	Arthroscopy, Knee, Surgical; Debridement/Shaving, Articular Cartilage (Chondroplasty)	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29879	Arthroscopy, Knee, Surgical; Abrasion Arthroplasty (W/Chondroplasty)/Multiple Drilling/Microfx	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29880	Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29881	Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same o	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29882	Arthroscopy, Knee, Surgical; W/Meniscus Repair, Medial/Lateral	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29883	Arthroscopy, Knee, Surgical; W/Meniscus Repair, Medial & Lateral	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29884	Arthroscopy, Knee, Surgical; W/Lysis, Adhesions, W/Wo Manipulation (Sep Proc)	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29885	Arthroscopy, Knee, Surgical; Drill, Osteochondritis Dissecans W/Bone Graft, W/Wo Int/Ext Fixation	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29886	Arthroscopy, Knee, Surgical; Drilling, Intact Osteochondritis Dissecans Lesion	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29887	Arthroscopy, Knee, Surgical; Drilling, Intact Osteochondritis Dissecans Lesion W/Int Fixation	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29888	Arthroscopically Aided Anterior Cruciate Ligament Repair/Augmentation/Reconstruction	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29889	Arthroscopically Aided Posterior Cruciate Ligament Repair/Augmentation/Reconstruction	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29892	Arthroscopically Aided Repair, Osteochondritis/Talar Dome Fx/Tibial Plafond Fx	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29914	Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)	Virginia PPO standard precertification/prior authorization requirements, Pg 20 Original policy
29915	Arthroscopy, subtalar joint, surgical; with acetabuloplasty (ie, treatment of pincer lesion)	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
29916	Arthroscopy, hip, surgical; with labral repair	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
30117	Excision/Destruction, Intranasal Lesion; Int Approach	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
30120	Excision/Surgical Planing, Skin, Nose, Rhinophyma	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
30400	Rhinoplasty, Primary; Lateral & Alar Cartilages &/Or Elevation, Nasal Tip	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
30410	Rhinoplasty, Primary; Complete, Ext Parts W/Bony Pyramid, Lat & Alar Cartilages &/Or Elev Nasal Tip	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy
30420	Rhinoplasty, Primary; W/Major Septal Repair	Virginia PPO standard precertification/prior authorization requirements, Pg 21 Original policy

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