AdministrativeAnthem Blue Cross and Blue Shield | CommercialOctober 1, 2022

Commercial-Local precertification list change notification

The following services will be added to precertification for the effective dates listed below.

Precertification responsibility

The ordering or rendering provider of service is responsible for completing the prior authorization process.

HMO plans: Services that require precertification will be denied if rendered without the appropriate prior authorization for in-network providers. HMO members may not have benefits for
non-emergency services rendered outside of the network and are subject to review and may be denied.

PPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement.

EPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement. No out-of-network benefit is available with the exception of ER/Urgent Care and authorized services.

To request precertification with the Virginia plan

Access Availity* at https://www.availity.com for Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc., or call the number listed on the back of the member’s ID card.

For mental health and substance abuse precertification, call 800-755-0851. Professionals are available 24 hours a day, seven days a week.

Add to Precertification

Criteria	Criteria description	Code	Effective date
LAB.00031	Advanced lipoprotein testing	0052U	Add 01/01/2023
MED.00118	Continuous monitoring of intraocular pressure	0329T	Add 01/01/2023
SURG.00150	Leadless pacemaker	33274	Add 01/01/2023
SURG.00150	Leadless pacemaker	33275	Add 01/01/2023
MED.00115	Outpatient cardiac hemodynamic monitoring using a wireless sensor for heart failure management	33289	Add 01/01/2023
SURG.00032	Patent foramen ovale and left atrial appendage closure devices for stroke prevention	33340	Add 01/01/2023
SURG.00121	Transcatheter heart valve procedures	33418	Add 01/01/2023
SURG.00116	High resolution anoscopy screening for anal intraepithelial neoplasia (AIN) and squamous cell cancer of the anus	46601	Add 01/01/2023
SURG.00116	High resolution anoscopy screening for anal intraepithelial neoplasia (AIN) and squamous cell cancer of the anus	46607	Add 01/01/2023
SURG.00010	Treatments for urinary incontinence	53445	Add 01/01/2023
SURG.00010	Treatments for urinary incontinence	53446	Add 01/01/2023
SURG.00010	Treatments for urinary incontinence	53448	Add 01/01/2023
SURG.00010	Treatments for urinary incontinence	53449	Add 01/01/2023
SURG.00077	Uterine fibroid ablation: laparoscopic, percutaneous or transcervical image guided techniques	58674	Add 01/01/2023
SURG.00026	Deep brain, cortical, and cerebellar stimulation	61850	Add 01/01/2023
SURG.00026	Deep brain, cortical, and cerebellar stimulation	61860	Add 01/01/2023
SURG.00144	Occipital nerve block therapy for the treatment of headache and occipital neuralgia	64405	Add 01/01/2023
SURG.00140	Peripheral nerve blocks for treatment of neuropathic pain	64415	Add 01/01/2023
SURG.00140	Peripheral nerve blocks for treatment of neuropathic pain	64417	Add 01/01/2023
SURG.00140	Peripheral nerve blocks for treatment of neuropathic pain	64447	Add 01/01/2023
SURG.00140; SURG.00144	Peripheral nerve blocks for treatment of neuropathic pain; occipital nerve block therapy for the treatment of headache and occipital neuralgia	64450	Add 01/01/2023
SURG.00151	Balloon dilation of the eustachian tubes	69705	Add 01/01/2023
SURG.00151	Balloon dilation of the eustachian tubes	69706	Add 01/01/2023
CG-MED-51; RAD.00038	Three-dimensional (3-D) rendering of imaging studies; use of 3-D, 4-D or 5-D ultrasound in maternity care	76376	Add 01/01/2023
CG-MED-51; RAD.00038	Three-dimensional (3-D) rendering of imaging studies; use of 3-D, 4-D or 5-D ultrasound in maternity care	76377	Add 01/01/2023
LAB.00033	Protein biomarkers for the screening, detection and management of prostate cancer	81539	Add 01/01/2023
MED.00125	Biofeedback and neurofeedback	90875	Add 01/01/2023
MED.00125	Biofeedback and neurofeedback	90876	Add 01/01/2023
MED.00115	Outpatient cardiac hemodynamic monitoring using a wireless sensor for heart failure management	93264	Add 01/01/2023
RAD.00064	Myocardial sympathetic innervation imaging with or without single-photon emission computed tomography (SPECT)	A9582	Add 01/01/2023
MED.00115	Outpatient cardiac hemodynamic monitoring using a wireless sensor for heart failure management	C2624	Add 01/01/2023
DME.00037	Cooling devices and combined cooling/heating devices	E0218	Add 01/01/2023
MED.00125	Biofeedback and neurofeedback	E0746	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J0558	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J0561	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J0690	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J0743	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J1267	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J1335	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J1956	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J2185	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J2280	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J2510	Add 01/01/2023

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc.

VABCBS-CM-006249-22

PUBLICATIONS: October 2022 Anthem Provider News - Virginia

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Commercial-Local precertification list change notification

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