Anthem Blue Cross and Blue Shield Virginia prior authorization code reference, page 87
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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
| Code | Description | Source |
|---|---|---|
| 36468 | Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36470 | Injection of sclerosant; single incompetent vein (other than telangiectasia) | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36471 | Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36473 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36475 | Endovenous Ablation Therapy Of Incompetent Vein, Extremity, Percutaneous, Radiofrequency; First Vein Treated | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36478 | Endovenous Ablation Therapy Of Incompetent Vein, Extremity, Percutaneous, Laser; First Vein Treated | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36482 | Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36511 | Therapeutic Apheresis; White Blood Cells | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36512 | Therapeutic Apheresis; Red Blood Cells | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36513 | Therapeutic Apheresis; Platelets | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36514 | Therapeutic Apheresis; Plasma Pheresis | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36516 | Therapeutic apheresis; with extracorporeal immunoadsorption, selective adsorption or selective filtration and plasma reinfusion | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36563 | Insertion of Tunneled Centrally Inserted Central Venous Access Device with Subcutaneous Pump | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36583 | Replacement, Complete, of a Tunneled Centrally Inserted Central Venous Access Device, w Sq Pump, Via Same Access | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36901 | Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s) | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36902 | Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s) | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36903 | Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s) | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36905 | Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis,dialysis circuit, any method, including all imaging and radiological supervision and interpr | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 36906 | Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis,dialysis circuit, any method, including all imaging and radiological supervision and interpr | Virginia PPO standard precertification/prior authorization requirements, Pg 23 Original policy |
| 37238 | Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same ves | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37241 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the i | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37242 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the i | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37243 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the i | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37244 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the i | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37248 | Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and intepretation necessary to perform ang | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37254 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37256 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37258 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37260 | Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37263 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37265 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37267 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37269 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37271 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37273 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37275 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37277 | Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37280 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37282 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37284 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37286 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37288 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37290 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37292 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37294 | Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37296 | Revascularization, endovascular, open or percutaneous, inframalleolar vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 37298 | Revascularization, endovascular, open or percutaneous, inframalleolar vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 38204 | Management, Recipient Hematopoietic Progenitor Cell Donor Search & Cell Acquisition | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 38205 | Blood-Derived Hematopoietic Progenitor Cell Harvesting, Transplantation/Collection; Allogenic | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |
| 38206 | Blood-Derived Hematopoietic Progenitor Cell Harvesting, Transplantation/Collection; Autologous | Virginia PPO standard precertification/prior authorization requirements, Pg 24 Original policy |