Anthem Blue Cross and Blue Shield New Hampshire policy
CG-MED-98 Parenteral Antibiotics for the Treatment of Lyme Disease
CG-MED-98 Parenteral Antibiotics for the Treatment of Lyme Disease is a public Anthem Blue Cross and Blue Shield New Hampshire policy (policy CG-MED-98). It lists 33 CPT or HCPCS codes, 30 of them on the Anthem Blue Cross and Blue Shield New Hampshire prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-MED-98
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross and Blue Shield New Hampshire prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield New Hampshire policies |
|---|---|---|---|
| 96365 | On the list | Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour | Policies naming 96365 |
| 96366 | Not listed | Policies naming 96366 | |
| 96367 | Not listed | Policies naming 96367 | |
| 96368 | Not listed | Policies naming 96368 | |
| 96372 | On the list | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular | Policies naming 96372 |
| J0456 | On the list | Injection, azithromycin, 500 mg | Policies naming J0456 |
| J0558 | On the list | Injection, penicillin G benzathine and penicillin G procaine, 100,000 units | Policies naming J0558 |
| J0561 | On the list | Injection, penicillin G benzathine, 100,000 units | Policies naming J0561 |
| J0687 | On the list | Injection, cefazolin sodium (WG Critical Care), not therapeutically equivalent to J0690, 500 mg | Policies naming J0687 |
| J0688 | On the list | Injection, cefazolin sodium (Hikma), not therapeutically equivalent to J0690, 500 mg | Policies naming J0688 |
| J0689 | On the list | Injection, cefazolin sodium (Baxter), not therapeutically equivalent to J0690, 500 mg | Policies naming J0689 |
| J0690 | On the list | Injection, cefazolin sodium, 500 mg | Policies naming J0690 |
| J0696 | On the list | Injection, ceftriaxone sodium, per 250 mg | Policies naming J0696 |
| J0698 | On the list | Injection, cefotaxime sodium, per g | Policies naming J0698 |
| J0743 | On the list | Injection, cilastatin sodium; imipenem, per 250 mg | Policies naming J0743 |
| J0744 | On the list | Injection, ciprofloxacin for intravenous infusion, 200 mg | Policies naming J0744 |
| J1335 | On the list | Injection, ertapenem sodium, 500 mg | Policies naming J1335 |
| J1450 | On the list | Injection, fluconazole, 200 mg | Policies naming J1450 |
| J1956 | On the list | Injection, levofloxacin, 250 mg | Policies naming J1956 |
| J2183 | On the list | Injection, meropenem (WG Critical Care), not therapeutically equivalent to J2185, 100 mg | Policies naming J2183 |
| J2184 | On the list | Injection, meropenem (B. Braun), not therapeutically equivalent to J2185, 100 mg | Policies naming J2184 |
| J2185 | On the list | Injection, meropenem, 100 mg | Policies naming J2185 |
| J2280 | On the list | Injection, moxifloxacin, 100 mg | Policies naming J2280 |
| J2281 | On the list | Injection, moxifloxacin (Fresenius Kabi), not therapeutically equivalent to J2280, 100 mg | Policies naming J2281 |
| J2510 | On the list | Injection, penicillin G procaine, aqueous, up to 600,000 units | Policies naming J2510 |
| J2540 | On the list | Injection, penicillin G potassium, up to 600,000 units | Policies naming J2540 |
| S9494 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code with home infusion codes for hourly dosing schedules S9497-S9504) | Policies naming S9494 |
| S9497 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 3 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem | Policies naming S9497 |
| S9500 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem | Policies naming S9500 |
| S9501 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem | Policies naming S9501 |
| S9502 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem | Policies naming S9502 |
| S9503 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal; once every 6 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem | Policies naming S9503 |
| S9504 | On the list | Home infusion therapy, antibiotic, antiviral, or antifungal; once every 4 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem | Policies naming S9504 |
All Anthem Blue Cross and Blue Shield New Hampshire policies · Anthem Blue Cross and Blue Shield New Hampshire prior authorization CPT list