Anthem Blue Cross and Blue Shield | CommercialMarch 1, 2024
Precertification list change notification
The following services will be added to precertification for the effective dates listed below.
Criteria | Criteria description | Code | Effective date |
CG-OR-PR-08 | Microprocessor Controlled Lower Limb Prosthesis | L7510 | June 1, 2024 |
CG-OR-PR-08 | Microprocessor Controlled Lower Limb Prosthesis | L7520 | June 1, 2024 |
CG-OR-PR-08 | Microprocessor Controlled Lower Limb Prosthesis | K1014 | June 1, 2024 |
CG-OR-PR-08 | Microprocessor Controlled Lower Limb Prosthesis | L5856 | June 1, 2024 |
CG-OR-PR-08 | Microprocessor Controlled Lower Limb Prosthesis | L5857 | June 1, 2024 |
CG-OR-PR-08 | Microprocessor Controlled Lower Limb Prosthesis | L5858 | June 1, 2024 |
CG-OR-PR-08 | Microprocessor Controlled Lower Limb Prosthesis | L5859 | June 1, 2024 |
CG-OR-PR-08 | Microprocessor Controlled Lower Limb Prosthesis | L5969 | June 1, 2024 |
CG-OR-PR-08 | Microprocessor Controlled Lower Limb Prosthesis | L5973 | June 1, 2024 |
CG-OR-PR-09 | Microprocessor Controlled Knee-Ankle-Foot Orthosis | L2006 | June 1, 2024 |
CG-SURG-61 | Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver | 53850 | June 1, 2024 |
CG-SURG-61 | Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver | 53852 | June 1, 2024 |
CG-SURG-61 | Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver | C9751 | June 1, 2024 |
CG-SURG-78 | Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies | C9790 | June 1, 2024 |
CG-SURG-79 | Implantable Infusion Pumps | E0786 | June 1, 2024 |
DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | E0769 | June 1, 2024 |
DME.00041 | Ultrasonic Diathermy Devices | K1036 | June 1, 2024 |
DME.00043 | Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring | E0490 | June 1, 2024 |
DME.00043 | Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring | E0491 | June 1, 2024 |
Carelon Medical Benefits Management, Inc. Guidelines | Carelon Medical Benefits Management Genetic Testing Guideline | 0403U | June 1, 2024 |
Carelon Medical Benefits Management Guidelines | Carelon Medical Benefits Management Genetic Testing Guideline | 0411U | June 1, 2024 |
Carelon Medical Benefits Management Guidelines | Carelon Medical Benefits Management Genetic Testing Guideline | 0419U | June 1, 2024 |
Carelon Medical Benefits Management Guidelines | Carelon Medical Benefits Management Genetic Testing Guideline | 0262U | June 1, 2024 |
Carelon Medical Benefits Management Guidelines | Carelon Medical Benefits Management Genetic Testing Guideline | 0405U | June 1, 2024 |
Carelon Medical Benefits Management Guidelines | Carelon Medical Benefits Management Genetic Testing Guideline | 0409U | June 1, 2024 |
Carelon Medical Benefits Management Guidelines | Carelon Medical Benefits Management Genetic Testing Guideline | 0410U | June 1, 2024 |
Carelon Medical Benefits Management Guidelines | Carelon Medical Benefits Management Genetic Testing Guideline | 0413U | June 1, 2024 |
Carelon Medical Benefits Management Guidelines | Carelon Medical Benefits Management Genetic Testing Guideline | 0414U | June 1, 2024 |
Carelon Medical Benefits Management Guidelines | Carelon Medical Benefits Management Genetic Testing Guideline | 0415U | June 1, 2024 |
Carelon Medical Benefits Management Guidelines | Carelon Medical Benefits Management Genetic Testing Guideline | 0417U | June 1, 2024 |
LAB.00011 | Selected Protein Biomarker Algorithmic Assays | 0342U | June 1, 2024 |
LAB.00028 | Blood-based Biomarker Tests for Multiple Sclerosis | 0361U | June 1, 2024 |
LAB.00040 | Serum Biomarker Tests for Risk of Preeclampsia | 0390U | June 1, 2024 |
LAB.00041 | Machine Learning Derived Probability Score for Rapid Kidney Function Decline | 0407U | June 1, 2024 |
LAB.00046 | Testing for Biochemical Markers for Alzheimer’s Disease | 0412U | June 1, 2024 |
MED.00143 | Ingestible Devices for the Treatment of Constipation | A9268 | June 1, 2024 |
MED.00143 | Ingestible Devices for the Treatment of Constipation | A9269 | June 1, 2024 |
MED.00145 | Digital Therapy Devices for Treatment of Amblyopia | A9292 | June 1, 2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | A2022 | June 1, 2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | A2023 | June 1, 2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | A2024 | June 1, 2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | A2025 | June 1, 2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | C1832 | June 1, 2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4285 | June 1, 2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4286 | June 1, 2024 |
SURG.00026 | Deep Brain, Cortical, and Cerebellar Stimulation | C1787 | June 1, 2024 |
SURG.00071 | Percutaneous and Endoscopic Spinal Surgery | C2614 | June 1, 2024 |
SURG.00144 | Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia | 64505 | June 1, 2024 |
TRANS.00009 | Portable Normothermic Organ Perfusion Systems | 0494T | June 1, 2024 |
TRANS.00009 | Portable Normothermic Organ Perfusion Systems | 0495T | June 1, 2024 |
TRANS.00009 | Portable Normothermic Organ Perfusion Systems | 0496T | June 1, 2024 |
Carelon Medical Benefits Management Guidelines | Carelon Medical Benefits Management Genetic Testing Guideline | 0088U | June 1, 2024 |
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.com.
For maternity, medical, surgical precertification, 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.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
VABCBS-CM-049258-24-SRS49256
PUBLICATIONS: March 2024 Provider Newsletter
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