Anthem Blue Cross and Blue Shield | CommercialJuly 1, 2024
Precertification list change notification July 1, 2024
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 nonemergency 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 (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.
Add to precertification | |||
Criteria | Criteria description | Code | Effective date |
CG-MED-79 | Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems | 33276 | 10/1/2024 |
CG-MED-79 | Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems | 33277 | 10/1/2024 |
CG-MED-79 | Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems | 33278 | 10/1/2024 |
CG-MED-79 | Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems | 33279 | 10/1/2024 |
CG-MED-79 | Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems | 33280 | 10/1/2024 |
CG-MED-79 | Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems | 33281 | 10/1/2024 |
CG-MED-79 | Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems | 33287 | 10/1/2024 |
CG-MED-79 | Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems | 33288 | 10/1/2024 |
CG-MED-79 | Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems | 93150 | 10/1/2024 |
CG-MED-79 | Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems | 93151 | 10/1/2024 |
CG-MED-79 | Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems | 93152 | 10/1/2024 |
CG-MED-79 | Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems | 93153 | 10/1/2024 |
CG-OR-PR-08 | Microprocessor Controlled Lower Limb Prosthesis | L5615 | 10/1/2024 |
CG-SURG-83 | Bariatric Surgery and Other Treatments for Clinically Severe Obesity | 0813T | 10/1/2024 |
DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | A4540 | 10/1/2024 |
DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | E0732 | 10/1/2024 |
DME.00042 | Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea | E0530 | 10/1/2024 |
DME.00043 | Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring | E0492 | 10/1/2024 |
DME.00043 | Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring | E0493 | 10/1/2024 |
DME.00046 | Intermittent Abdominal Pressure Ventilation Devices | A4468 | 10/1/2024 |
DME.00049 | External Upper Limb Stimulation for the Treatment of Tremors | A4542 | 10/1/2024 |
DME.00049 | External Upper Limb Stimulation for the Treatment of Tremors | E0734 | 10/1/2024 |
GENE.00010 | Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status | 0423U | 10/1/2024 |
GENE.00010 | Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status | 0434U | 10/1/2024 |
GENE.00010 | Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status | 0438U | 10/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 81457 | 10/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 81458 | 10/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 81459 | 10/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 81462 | 10/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 81463 | 10/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 81464 | 10/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0422U | 10/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0424U | 10/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0425U | 10/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0426U | 10/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0428U | 10/1/2024 |
GENE.00056 | Gene Expression Profiling for Bladder Cancer | 0420U | 10/1/2024 |
LAB.00003 | In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays | 0435U | 10/1/2024 |
LAB.00016 | Fecal Analysis in the Diagnosis of Intestinal Disorders | 0430U | 10/1/2024 |
LAB.00019 | Proprietary Algorithms for Liver Fibrosis | 81517 | 10/1/2024 |
LAB.00050 | Metagenomic Sequencing for Infectious Disease in the Outpatient Setting | 0112U | 10/1/2024 |
LAB.00050 | Metagenomic Sequencing for Infectious Disease in the Outpatient Setting | 0152U | 10/1/2024 |
LAB.00050 | Metagenomic Sequencing for Infectious Disease in the Outpatient Setting | 0323U | 10/1/2024 |
MED.00130 | Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring | E0746 | 10/1/2024 |
RAD.00068 | Myocardial Strain Imaging | C9762 | 10/1/2024 |
RAD.00068 | Myocardial Strain Imaging | C9763 | 10/1/2024 |
SURG.00007 | Vagus Nerve Stimulation | E0735 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4279 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4287 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4288 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4289 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4290 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4291 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4292 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4293 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4294 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4295 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4296 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4297 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4298 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4299 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4300 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4301 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4302 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4303 | 10/1/2024 |
SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4304 | 10/1/2024 |
SURG.00026 | Deep Brain, Cortical, and Cerebellar Stimulation | 61889 | 10/1/2024 |
SURG.00026 | Deep Brain, Cortical, and Cerebellar Stimulation | 61891 | 10/1/2024 |
SURG.00026 | Deep Brain, Cortical, and Cerebellar Stimulation | C1778 | 10/1/2024 |
SURG.00045 | Extracorporeal Shock Wave Therapy | 0864T | 10/1/2024 |
SURG.00077 | Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques | 58580 | 10/1/2024 |
SURG.00097 | Scoliosis Surgery | 22836 | 10/1/2024 |
SURG.00097 | Scoliosis Surgery | 22837 | 10/1/2024 |
SURG.00097 | Scoliosis Surgery | 22838 | 10/1/2024 |
SURG.00097 | Scoliosis Surgery | 0790T | 10/1/2024 |
SURG.00142 | Genicular Procedures for Treatment of Knee Pain | 37242 | 10/1/2024 |
SURG.00150 | Leadless Pacemaker | 0823T | 10/1/2024 |
SURG.00150 | Leadless Pacemaker | 0824T | 10/1/2024 |
SURG.00150 | Leadless Pacemaker | 0825T | 10/1/2024 |
SURG.00150 | Leadless Pacemaker | 0826T | 10/1/2024 |
SURG.00152 | Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing | 0861T | 10/1/2024 |
SURG.00152 | Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing | 0862T | 10/1/2024 |
SURG.00152 | Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing | 0863T | 10/1/2024 |
SURG.00157 | Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis | 31242 | 10/1/2024 |
SURG.00157 | Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis | 31243 | 10/1/2024 |
SURG.00158 | Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain | 64596 | 10/1/2024 |
SURG.00158 | Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain | 64597 | 10/1/2024 |
UM AROW# A2024M1436
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-058792-24-CPN57724
PUBLICATIONS: July 2024 Provider Newsletter
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