Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 10
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 |
|---|---|---|
| 0442T | Ablation, percutaneous, cryoablation, inclu | New Hampshire Precertification List, Pg 55 Original policy |
| 0444U | Oncology (solid organ neoplasia), targeted | New Hampshire Precertification List, Pg 55 Original policy |
| 0445U | B-amyloid (Abeta42) and phospho tau (181P) (pTau181), electrochemiluminescent immunoassay (ECLIA), cerebral spinal fluid, ratio reported as positive or negative for amyloid pathology | New Hampshire Precertification List, Pg 55 Original policy |
| 0449T | Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device | New Hampshire Precertification List, Pg 55 Original policy |
| 0449U | Carrier screening for severe inherited con | New Hampshire Precertification List, Pg 55 Original policy |
| 0450T | Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; each additional device (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 55 Original policy |
| 0452U | Oncology (bladder), methylated PENK DN | New Hampshire Precertification List, Pg 55 Original policy |
| 0453U | Oncology (colorectal cancer), cell-free DN | New Hampshire Precertification List, Pg 55 Original policy |
| 0454U | Rare diseases (constitutional/heritable dis | New Hampshire Precertification List, Pg 55 Original policy |
| 0457U | Perfluoroalkyl substances (PFAS) (eg, perfluorooctanoic acid, perfluorooctane sulfonic acid), 9 PFAS compounds by LC- MS/MS, plasma or serum, quantitative | New Hampshire Precertification List, Pg 55 Original policy |
| 0459U | B-amyloid (Abeta42) and total tau (tTau), electrochemiluminescent immunoassay (ECLIA), cerebral spinal fluid, ratio reported as positive or negative for amyloid pathology | New Hampshire Precertification List, Pg 55 Original policy |
| 0460U | Oncology, whole blood or buccal, DNA sin | New Hampshire Precertification List, Pg 55 Original policy |
| 0461U | Oncology, pharmacogenomic analysis of s | New Hampshire Precertification List, Pg 55 Original policy |
| 0465U | Oncology (urothelial carcinoma), DNA, qu | New Hampshire Precertification List, Pg 55 Original policy |
| 0466U | Cardiology (coronary artery disease [CAD] | New Hampshire Precertification List, Pg 55 Original policy |
| 0467U | Oncology (bladder), DNA, next-generation | New Hampshire Precertification List, Pg 55 Original policy |
| 0468U | Hepatology (nonalcoholic steatohepatitis [NASH]), miR-34a-5p, alpha 2- macroglobulin, YKL40, HbA1c, serum and whole blood, algorithm reported as a single score for NASH activity and fibrosis | New Hampshire Precertification List, Pg 56 Original policy |
| 0469U | Rare diseases (constitutional/heritable dis | New Hampshire Precertification List, Pg 56 Original policy |
| 0471U | Oncology (colorectal cancer), qualitative r | New Hampshire Precertification List, Pg 56 Original policy |
| 0472T | Device evaluation, interrogation, and initial programming of intraocular retinal electrode array (eg, retinal prosthesis), in person, with iterative adjustment of the implantable device to test functionality, select optimal permanent programmed values with analysis, including visual training, with review and report by a qualified health care professional | New Hampshire Precertification List, Pg 56 Original policy |
| 0473T | Device evaluation and interrogation of intraocular retinal electrode array (eg, retinal prosthesis), in person, including reprogramming and visual training, when performed, with review and report by a qualified health care professional | New Hampshire Precertification List, Pg 56 Original policy |
| 0473U | Oncology (solid tumor), next-generation s | New Hampshire Precertification List, Pg 56 Original policy |
| 0474T | Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space | New Hampshire Precertification List, Pg 56 Original policy |
| 0474U | Hereditary pan-cancer (eg, hereditary sarc | New Hampshire Precertification List, Pg 56 Original policy |
| 0475U | Hereditary prostate cancer-related disorde | New Hampshire Precertification List, Pg 56 Original policy |
| 0476U | Drug metabolism, psychiatry (eg, major de | New Hampshire Precertification List, Pg 56 Original policy |
| 0477U | Drug metabolism, psychiatry (eg, major de | New Hampshire Precertification List, Pg 56 Original policy |
| 0478U | Oncology (non-small cell lung cancer), DN | New Hampshire Precertification List, Pg 56 Original policy |
| 0479U | Tau, phosphorylated, pTau217 | New Hampshire Precertification List, Pg 56 Original policy |
| 0480U | Infectious disease (bacteria, viruses, fungi, and parasites), cerebrospinal fluid (CSF), metagenomic next-generation sequencing (DNA and RNA), bioinformatic analysis, with pos | New Hampshire Precertification List, Pg 56 Original policy |
| 0481T | Injection(s), autologous white blood cell concentrate (autologous protein solution), any site, including image guidance, harvesting and preparation, when performed | New Hampshire Precertification List, Pg 56 Original policy |
| 0481U | IDH1 (isocitrate dehydrogenase 1 [NADP+ | New Hampshire Precertification List, Pg 56 Original policy |
| 0482U | Obstetrics (preeclampsia), biochemical assay of soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF), serum, ratio reported for sFlt- 1/PlGF, with ris | New Hampshire Precertification List, Pg 56 Original policy |
| 0483T | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed | New Hampshire Precertification List, Pg 56 Original policy |
| 0484T | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (eg, thoracotomy, transapical) | New Hampshire Precertification List, Pg 57 Original policy |
| 0485U | Oncology (solid tumor), cell-free DNA and | New Hampshire Precertification List, Pg 57 Original policy |
| 0486U | Oncology (pan-solid tumor), next-generati | New Hampshire Precertification List, Pg 57 Original policy |
| 0487U | Oncology (solid tumor), cell-free circulatin | New Hampshire Precertification List, Pg 57 Original policy |
| 0488U | Obstetrics (fetal antigen noninvasive pren | New Hampshire Precertification List, Pg 57 Original policy |
| 0489T | Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cells | New Hampshire Precertification List, Pg 57 Original policy |
| 0489U | Obstetrics (single-gene noninvasive prena | New Hampshire Precertification List, Pg 57 Original policy |
| 0490T | Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands | New Hampshire Precertification List, Pg 57 Original policy |
| 0490U | Oncology (cutaneous or uveal melanoma), circulating tumor cell selection, morphological characterization and enumeration based on differential CD146, high molecular-weight mel | New Hampshire Precertification List, Pg 57 Original policy |
| 0491U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytok | New Hampshire Precertification List, Pg 57 Original policy |
| 0492U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytok | New Hampshire Precertification List, Pg 57 Original policy |
| 0493U | Transplantation medicine, quantification o | New Hampshire Precertification List, Pg 57 Original policy |
| 0494T | Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system, including decannulation, separation from the perfusion system, and cold preservation of the allograft prior to implantation, when performed | New Hampshire Precertification List, Pg 57 Original policy |
| 0494U | Red blood cell antigen (fetal RhD gene an | New Hampshire Precertification List, Pg 57 Original policy |
| 0495T | Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (eg, pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; first two hours in sterile field | New Hampshire Precertification List, Pg 58 Original policy |
| 0495U | Oncology (prostate), analysis of circulating plasma proteins (tPSA, fPSA, KLK2, PSP94, and GDF15), germline polygenic risk score (60 variants), clinical information (age, fami | New Hampshire Precertification List, Pg 58 Original policy |