Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 13
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 |
|---|---|---|
| 0597U | Oncology (breast), RNA expression profiling of 329 genes by targeted next- generation sequencing and 20 proteins by multiplex immunofluorescence, formalin-fixed paraffin-embedd | New Hampshire Precertification List, Pg 64 Original policy |
| 0600T | Ablation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance, when performed, percutaneous | New Hampshire Precertification List, Pg 64 Original policy |
| 0601T | Ablation, irreversible electroporation; 1 or more tumors per organ, including fluoroscopic and ultrasound guidance, when performed, open | New Hampshire Precertification List, Pg 64 Original policy |
| 0607T | Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ECG data), transmitted to a remote 24-hour attended surveillance center; set-up and patient education on use of equipment | New Hampshire Precertification List, Pg 64 Original policy |
| 0608T | Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ECG data), transmitted to a remote 24-hour attended surveillance center; analysis of data received and transmission of reports to the physician or other qualified health care professional | New Hampshire Precertification List, Pg 65 Original policy |
| 0615T | Automated analysis of binocular eye movements without spatial calibration, including disconjugacy, saccades, and pupillary dynamics for the assessment of concussion, with interpretation and report | New Hampshire Precertification List, Pg 65 Original policy |
| 0620T | Endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed | New Hampshire Precertification List, Pg 65 Original policy |
| 0627T | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level | New Hampshire Precertification List, Pg 65 Original policy |
| 0628T | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; each additional level (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 65 Original policy |
| 0629T | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level | New Hampshire Precertification List, Pg 65 Original policy |
| 0630T | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; each additional level (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 65 Original policy |
| 0633T | Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast material | New Hampshire Precertification List, Pg 66 Original policy |
| 0634T | Computed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s) | New Hampshire Precertification List, Pg 66 Original policy |
| 0635T | Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s) | New Hampshire Precertification List, Pg 66 Original policy |
| 0636T | Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s) | New Hampshire Precertification List, Pg 66 Original policy |
| 0637T | Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s) | New Hampshire Precertification List, Pg 66 Original policy |
| 0638T | Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s) | New Hampshire Precertification List, Pg 66 Original policy |
| 0646T | Transcatheter tricuspid valve implantation (TTVI)/replacement with prosthetic valve, percutaneous approach, including right heart catheterization, temporary pacemaker insertion, and selective right ventricular or right atrial angiography, when performed | New Hampshire Precertification List, Pg 66 Original policy |
| 0648T | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure) during the same session; single organ | New Hampshire Precertification List, Pg 66 Original policy |
| 0652T | Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | New Hampshire Precertification List, Pg 66 Original policy |
| 0653T | Esophagogastroduodenoscopy, flexible, transnasal; with biopsy, single or multiple | New Hampshire Precertification List, Pg 66 Original policy |
| 0654T | Esophagogastroduodenoscopy, flexible, transnasal; with insertion of intraluminal tube or catheter | New Hampshire Precertification List, Pg 66 Original policy |
| 0655T | Transperineal focal laser ablation of malignant prostate tissue, including transrectal imaging guidance, with MR- fused images or other enhanced ultrasound imaging | New Hampshire Precertification List, Pg 67 Original policy |
| 0656T | Anterior lumbar or thoracolumbar vertebral body tethering; up to 7 vertebral segments | New Hampshire Precertification List, Pg 67 Original policy |
| 0657T | Anterior lumbar or thoracolumbar vertebral body tethering; 8 or more vertebral segments | New Hampshire Precertification List, Pg 67 Original policy |
| 0658T | Electrical impedance spectroscopy of 1 or more skin lesions for automated melanoma risk score | New Hampshire Precertification List, Pg 67 Original policy |
| 0659T | Transcatheter intracoronary infusion of supersaturated oxygen in conjunction with percutaneous coronary revascularization during acute myocardial infarction, including catheter placement, imaging guidance (eg, fluoroscopy), angiography, and radiologic supervision and interpretation | New Hampshire Precertification List, Pg 67 Original policy |
| 0664T | Donor hysterectomy (including cold preservation); open, from cadaver donor | New Hampshire Precertification List, Pg 67 Original policy |
| 0665T | Donor hysterectomy (including cold preservation); open, from living donor | New Hampshire Precertification List, Pg 67 Original policy |
| 0666T | Donor hysterectomy (including cold preservation); laparoscopic or robotic, from living donor | New Hampshire Precertification List, Pg 67 Original policy |
| 0667T | Donor hysterectomy (including cold preservation); recipient uterus allograft transplantation from cadaver or living donor | New Hampshire Precertification List, Pg 67 Original policy |
| 0668T | Backbench standard preparation of cadaver or living donor uterine allograft prior to transplantation, including dissection and removal of surrounding soft tissues and preparation of uterine vein(s) and uterine artery(ies), as necessary | New Hampshire Precertification List, Pg 67 Original policy |
| 0669T | Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; venous anastomosis, each | New Hampshire Precertification List, Pg 67 Original policy |
| 0670T | Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; arterial anastomosis, each | New Hampshire Precertification List, Pg 67 Original policy |
| 0671T | Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more | New Hampshire Precertification List, Pg 67 Original policy |
| 0672T | Endovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence | New Hampshire Precertification List, Pg 68 Original policy |
| 0673T | Ablation, benign thyroid nodule(s), percutaneous, laser, including imaging guidance | New Hampshire Precertification List, Pg 68 Original policy |
| 0686T | Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance | New Hampshire Precertification List, Pg 68 Original policy |
| 0687T | Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session | New Hampshire Precertification List, Pg 68 Original policy |
| 0688T | Treatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified health care professional, with report, per calendar month | New Hampshire Precertification List, Pg 68 Original policy |
| 0689T | Quantitative ultrasound tissue characterization (non-elastographic), including interpretation and report, obtained without diagnostic ultrasound examination of the same anatomy (eg, organ, gland, tissue, target structure) | New Hampshire Precertification List, Pg 68 Original policy |
| 0690T | Quantitative ultrasound tissue characterization (non-elastographic), including interpretation and report, obtained with diagnostic ultrasound examination of the same anatomy (eg, organ, gland, tissue, target structure) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 68 Original policy |
| 0692T | Therapeutic ultrafiltration | New Hampshire Precertification List, Pg 68 Original policy |
| 0700T | Molecular fluorescent imaging of suspicious nevus; first lesion | New Hampshire Precertification List, Pg 68 Original policy |
| 0701T | Molecular fluorescent imaging of suspicious nevus; each additional lesion (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 68 Original policy |
| 0704T | Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment | New Hampshire Precertification List, Pg 68 Original policy |
| 0705T | Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hours, each 30 days | New Hampshire Precertification List, Pg 68 Original policy |
| 0706T | Remote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified health care professional, per calendar month | New Hampshire Precertification List, Pg 69 Original policy |
| 0707T | Injection(s), bone-substitute material (eg, calcium phosphate) into subchondral bone defect (ie, bone marrow lesion, bone bruise, stress injury, microtrabecular fracture), including imaging guidance and arthroscopic assistance for joint visualization | New Hampshire Precertification List, Pg 69 Original policy |
| 0717T | Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, including incubation with cell dissociation enzymes, filtration, washing and concentration of ADRCs | New Hampshire Precertification List, Pg 69 Original policy |