Anthem Blue Cross and Blue Shield | Medicare AdvantageJuly 15, 2025
Prior authorization requirement changes
Effective November 1, 2025, precertification/prior authorization requirements will change for the following code(s). The medical code(s) listed below will require precertification/prior authorization by Anthem for Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage.
If the requirements are not met, those services may be deemed ineligible for payment.
Care providers may appeal online through Availity Essentials (https://Availity.com) or contact Provider Services via the number on the back of our member ID card with additional information, which may include medical records.
Precertification/prior authorization requirements will be added for the following code(s):
This applies to all Medicare, FIDE (Fully Integrated Dual Eligible), and Institutional Special Needs Plans (I‑SNPs) offered in Virginia.
0521U | Rheumatoid factor IgA and IgM, cyclic citrullinated peptide (CCP) antibodies, and scavenger receptor A (SR-A) by immunoassay, blood |
0524U | Obstetrics (preeclampsia), sFlt1/PlGF ratio, immunoassay, utilizing serum or plasma, reported as a value |
0525U | Oncology, spheroid cell culture, 11-drug panel (carboplatin, docetaxel, doxorubicin, etoposide, gemcitabine, niraparib, olaparib, paclitaxel, rucaparib, topotecan, veliparib) |
0686T | Histotripsy (i.e., non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance |
0888T | Histotripsy (i.e., non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including imaging guidance |
0935T | Cystourethroscopy with renal pelvic sympathetic denervation, radiofrequency ablation, retrograde ureteral approach, including insertion of guide wire, selective placement of ureteral sheath(s) and multiple conformable electrodes, contrast injection(s), and fluoroscopy, bilateral |
60660 | Percutaneous ablation of 1 or more thyroid nodule(s) |
60661 | Percutaneous ablation of additional lobe of thyroid nodule(s) |
61715 | MRI guided focused ultrasound high intensity stereotactic intracranial ablation |
82233 | Beta-amyloid; 1-40 |
82234 | Beta-amyloid; 1-42 |
83884 | Neurofilament light chain |
84393 | Tau, phosphorylated |
84394 | Tau, total |
C1735 | Catheter(s), intravascular for renal denervation, radiofrequency, including all single use system components |
C1736 | Catheter(s), intravascular for renal denervation, ultrasound, including all single use system components |
C8003 | Implantation of medial knee extraarticular implantable shock absorber spanning the knee joint from distal femur to proximal tibia, open, includes measurements, positioning and adjustments, with imaging guidance (e.g., fluoroscopy) |
C9804 | Elastomeric infusion pump (e.g., On-Q* pump with bolus), including catheter and all disposable system components, nonopioid medical device (must be a qualifying Medicare nonopioid medical device for postsurgical pain relief in accordance with Section 4135 of the CAA, 2023) |
C9808 | Nerve cryoablation probe (e.g., cryoICE, cryoSPHERE, cryoSPHERE MAX, cryo2), including probe and all disposable system components, nonopioid medical device (must be a qualifying Medicare nonopioid medical device for postsurgical pain relief in accordance with Section 4135 of the CAA, 2023) |
C9809 | Cryoablation needle (e.g., iovera system), including needle/tip and all disposable system components, nonopioid medical device (must be a qualifying Medicare nonopioid medical device for postsurgical pain relief in accordance with Section 4135 of the CAA, 2023) |
E0683 | Non-pneumatic, non-sequential, peristaltic wave compression pump |
E0739 | Rehabilitation system with interactive interface providing active assistance in rehabilitation therapy, includes all components and accessories, motors, microprocessors, sensors |
E1822 | Dynamic adjustable ankle extension only device, includes soft interface material |
E1823 | Dynamic adjustable ankle flexion only device, includes soft interface material |
E1828 | Dynamic adjustable toe extension only device, includes soft interface material |
E1829 | Dynamic adjustable toe flexion only device, includes soft interface material |
This applies to FIDE (Fully Integrated Dual Eligible) and Institutional Special Needs Plans (I‑SNPs) offered in Virginia.
0909T | Replacement of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed |
0910T | Removal of integrated neurostimulation system, vagus nerve |
0911T | Electronic analysis of implanted integrated neurostimulation system, vagus nerve; without programming by physician or other qualified health care professional |
0912T | Electronic analysis of implanted integrated neurostimulation system, vagus nerve; with simple programming by physician or other qualified health care professional |
15011 | Harvest of skin for autograft; first |
15012 | Harvest of skin for autograft; each additional 25 sq cm |
15013 | Preparation of skin autograft, requiring enzymatic processing; first 25 sq cm or less |
15014 | Preparation of skin autograft, requiring enzymatic processing; each additional 25 sq cm |
15015 | Application of skin autograft; first 480 sq cm or less |
15016 | Application of skin autograft; each additional 480 sq cm |
15017 | Application of skin autograft; first 480 sq cm or less |
15018 | Application of skin autograft; each additional 480 sq cm |
C8002 | Preparation of skin cell suspension autograft, automated, including all enzymatic processing and device components (do not report with manual suspension preparation) |
This applies to FIDE (Fully Integrated Dual Eligible) offered in Virginia.
0908T | Open implantation of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed |
66683 | Iris prosthesis Implantation |
C9807 | Nerve stimulator, percutaneous, peripheral (e.g., sprint peripheral nerve stimulation system), including electrode and all disposable system components, nonopioid medical device (must be a qualifying Medicare nonopioid medical device for postsurgical pain relief in accordance with Section 4135 of the CAA, 2023) |
J1414 | Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose |
J3392 | Injection, exagamglogene autotemcel, per treatment |
Q4346 | Shelter dm matrix, per square centimeter |
Q4347 | Rampart dl matrix, per square centimeter |
Q4348 | Sentry sl matrix, per square centimeter |
Q4349 | Mantle dl matrix, per square centimeter |
Q4350 | Palisade dm matrix, per square centimeter |
Q4351 | Enclose tl matrix, per square centimeter |
Q4352 | Overlay sl matrix, per square centimeter |
Q4353 | Xceed tl matrix, per square centimeter |
Not all precertification/prior authorization requirements are listed here. Detailed precertification/prior authorization requirements are available to care providers on https://www.anthem.com/va/provider or for contracted care providers by accessing https://Availity.com. Care providers may also contact Provider Services via the number on the back of our member ID card for assistance with precertification/prior authorization requirements.
Published in the August 2025 Provider Newsletter
UM AROW A2025M3432 A2025M3433 A2025M3437
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.
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