Anthem Blue Cross and Blue Shield New Hampshire prior authorization
CPT code lookup
Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| 11922 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 2 Original policy |
| 15151 | Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 2 Original policy |
| 15152 | Tissue cultured skin autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 2 Original policy |
| 15156 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 2 Original policy |
| 15157 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 3 Original policy |
| 15272 | Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 3 Original policy |
| 15274 | Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 3 Original policy |
| 15276 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 3 Original policy |
| 15278 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 3 Original policy |
| 15772 | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 3 Original policy |
| 15774 | Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 3 Original policy |
| 15777 | Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 4 Original policy |
| 15787 | Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 4 Original policy |
| 15847 | Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 4 Original policy |
| 20939 | Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 4 Original policy |
| 27280 | Arthrodesis, sacroiliac joint, open, includes obtaining bone graft, including instrumentation, when performed | New Hampshire Precertification List, Pg 4 Original policy |
| 30520 | Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft | New Hampshire Precertification List, Pg 4 Original policy |
| 30620 | Septal or other intranasal dermatoplasty (does not include obtaining graft) | New Hampshire Precertification List, Pg 4 Original policy |
| 31237 | Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) | New Hampshire Precertification List, Pg 4 Original policy |
| 31253 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed | New Hampshire Precertification List, Pg 4 Original policy |
| 31254 | Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior) | New Hampshire Precertification List, Pg 4 Original policy |
| 31255 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) | New Hampshire Precertification List, Pg 4 Original policy |
| 31256 | Nasal/sinus endoscopy, surgical, with maxillary antrostomy | New Hampshire Precertification List, Pg 4 Original policy |
| 31257 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy | New Hampshire Precertification List, Pg 4 Original policy |
| 31259 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus | New Hampshire Precertification List, Pg 4 Original policy |
| 31267 | Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus | New Hampshire Precertification List, Pg 4 Original policy |
| 31276 | Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed | New Hampshire Precertification List, Pg 5 Original policy |
| 31287 | Nasal/sinus endoscopy, surgical, with sphenoidotomy | New Hampshire Precertification List, Pg 5 Original policy |
| 31288 | Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus | New Hampshire Precertification List, Pg 5 Original policy |
| 31295 | Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa | New Hampshire Precertification List, Pg 5 Original policy |
| 31296 | Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium | New Hampshire Precertification List, Pg 5 Original policy |
| 31297 | Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); sphenoid sinus ostium | New Hampshire Precertification List, Pg 5 Original policy |
| 31298 | Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia | New Hampshire Precertification List, Pg 5 Original policy |
| 33277 | Insertion of phrenic nerve stimulator transvenous sensing lead (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 5 Original policy |
| 36260 | Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver) | New Hampshire Precertification List, Pg 5 Original policy |
| 36261 | Revision of implanted intra-arterial infusion pump | New Hampshire Precertification List, Pg 5 Original policy |
| 36474 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 5 Original policy |
| 36476 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 5 Original policy |
| 36479 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 5 Original policy |
| 36483 | Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 6 Original policy |
| 36563 | Insertion of tunneled centrally inserted central venous access device with subcutaneous pump | New Hampshire Precertification List, Pg 6 Original policy |
| 36583 | Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous pump, through same venous access | New Hampshire Precertification List, Pg 6 Original policy |
| 36901 | Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report | New Hampshire Precertification List, Pg 6 Original policy |
| 36902 | Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty | New Hampshire Precertification List, Pg 6 Original policy |
| 36903 | Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment | New Hampshire Precertification List, Pg 7 Original policy |
| 36905 | Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty | New Hampshire Precertification List, Pg 7 Original policy |
| 36906 | Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis circuit | New Hampshire Precertification List, Pg 7 Original policy |
| 36907 | Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the angioplasty (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 8 Original policy |
| 36908 | Transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the stenting, and all angioplasty in the central dialysis segment (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 8 Original policy |
| 37216 | Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; without distal embolic protection | New Hampshire Precertification List, Pg 8 Original policy |