Anthem Blue Cross and Blue Shield Virginia prior authorization code reference, page 89

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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
83700	Lipoprotein, blood; electrophoretic separation and	Virginia PPO standard precertification/prior authorization requirements, Pg 41 Original policy
83701	Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when	Virginia PPO standard precertification/prior authorization requirements, Pg 41 Original policy
83704	Lipoprotein, blood; quantitation of lipoprotein particle number(s) (eg, by nuclear magnetic resonance spectroscopy), includes lipoprotein particle subclass(es), when performed	Virginia PPO standard precertification/prior authorization requirements, Pg 41 Original policy
99500	Home Visit, Prenat Monitor Assess, Fetal Heart Rate, Non-Stress Test, Uterine, Gestat Diabet Monitor	Virginia PPO standard precertification/prior authorization requirements, Pg 46 Original policy
99503	Home Visit, Respiratory Therapy Care (Bronchodilator, Oxygen Therapy, Resp Assess, Apnea Eval)	Virginia PPO standard precertification/prior authorization requirements, Pg 46 Original policy
99504	Home Visit, Mechanical Ventilation Care	Virginia PPO standard precertification/prior authorization requirements, Pg 46 Original policy
99505	Home Visit, Stoma Care & Maintenance, Colostomy, Cystostomy	Virginia PPO standard precertification/prior authorization requirements, Pg 46 Original policy
99506	Home Visit, Im Injections	Virginia PPO standard precertification/prior authorization requirements, Pg 46 Original policy
99507	Home Visit, Care & Maintenance Catheter(S) (Therapy, Drainage, Enteral)	Virginia PPO standard precertification/prior authorization requirements, Pg 46 Original policy
99509	Home Visit, Assistance W/Activities Daily Living & Personal Care	Virginia PPO standard precertification/prior authorization requirements, Pg 46 Original policy
99511	Home Visit, Fecal Impaction Management & Enema Administration	Virginia PPO standard precertification/prior authorization requirements, Pg 46 Original policy
99512	Home Visit, Hemodialysis	Virginia PPO standard precertification/prior authorization requirements, Pg 46 Original policy
99600	Unlisted Home Visit Service/Procedure	Virginia PPO standard precertification/prior authorization requirements, Pg 46 Original policy
G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes	Virginia PPO standard precertification/prior authorization requirements, Pg 53 Original policy
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes	Virginia PPO standard precertification/prior authorization requirements, Pg 53 Original policy
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes	Virginia PPO standard precertification/prior authorization requirements, Pg 53 Original policy
G0155	Services Of Clinical Social Worker In Home Health Or Hospice Settings, Each 15 Minutes	Virginia PPO standard precertification/prior authorization requirements, Pg 54 Original policy
G0156	Services Of Home Health/Hospice Aide In Home Health Or Hospice Settings, Each 15 Minutes	Virginia PPO standard precertification/prior authorization requirements, Pg 54 Original policy
G0157	Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes	Virginia PPO standard precertification/prior authorization requirements, Pg 54 Original policy
G0158	Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes	Virginia PPO standard precertification/prior authorization requirements, Pg 54 Original policy
G0159	Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program	Virginia PPO standard precertification/prior authorization requirements, Pg 54 Original policy
G0160	Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance	Virginia PPO standard precertification/prior authorization requirements, Pg 54 Original policy
G0161	Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology m	Virginia PPO standard precertification/prior authorization requirements, Pg 54 Original policy
G0162	Skilled services by a registered nurse (RN) for management & evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN	Virginia PPO standard precertification/prior authorization requirements, Pg 54 Original policy
G0320	Home health services furnished using synchronous telemedicine rendered via a real-time two- way audio and video telecommunications system	Virginia PPO standard precertification/prior authorization requirements, Pg 54 Original policy
G0321	Home health services furnished using synchronous telemedicine rendered via telephone or other real-time interactive audio-only telecommunications system	Virginia PPO standard precertification/prior authorization requirements, Pg 54 Original policy
G0322	The collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (i.e., remote patient monitoring)	Virginia PPO standard precertification/prior authorization requirements, Pg 54 Original policy
G2168	Services performed by a physical therapist assistant in the home health setting in the delivery of a safe and effective physical therapy maintenance program, each 15 minutes	Virginia PPO standard precertification/prior authorization requirements, Pg 54 Original policy
G2169	Services performed by an occupational therapist assistant in the home health setting in the delivery of a safe and effective occupational therapy maintenance program, each 15	Virginia PPO standard precertification/prior authorization requirements, Pg 54 Original policy
J1943	Injection, aripiprazole lauroxil, (aristada initio), 1 mg	Virginia PPO standard precertification/prior authorization requirements, Pg 58 Original policy
Q5001	Hospice or home health care provided in patient's home/residence	Virginia PPO standard precertification/prior authorization requirements, Pg 72 Original policy
Q5002	Hospice or home health care provided in assisted living facility	Virginia PPO standard precertification/prior authorization requirements, Pg 72 Original policy
Q5009	Hospice or home health care provided in place not otherwise specified (nos)	Virginia PPO standard precertification/prior authorization requirements, Pg 72 Original policy
S5035	Home infusion therapy, routine service of infusion device (e.g., pump maintenance)	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5036	Home infusion therapy, repair of infusion device (e.g., pump repair)	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5108	Home care training to home care client, per 15 minutes	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5109	Home care training to home care client, per 15 minutes per session	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5110	Home Care Training, Family, Per 15 Minutes	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5111	Home Care Training, Family, Per Session	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5115	Home Care Training, Non-Family, Per 15 Minutes	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5116	Home Care Training, Non-Family, Per Session	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5180	Home Health Respiratory Therapy, Initial Evaluation	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5497	Home infusion therapy, catheter care/maintenance, not otherwise classified	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5498	Home infusion therapy, catheter care/maintenance, simple (single lumen)	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5501	Home infusion therapy, catheter care/maintenance, complex (more than one lumen)	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5502	Home infusion therapy, catheter care/maintenance, implanted access device	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5517	Home infusion therapy, all supplies necessary for restoration of catheter potency or declotting	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5518	Home infusion therapy, all supplies necessary for catheter repair	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5520	Home infusion therapy, all supplies (including catheter) necessary for a peripherally inserted central venous catheter (	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy
S5521	Home infusion therapy, all supplies (including catheter) necessary for midline catheter insertion	Virginia PPO standard precertification/prior authorization requirements, Pg 74 Original policy

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