Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 14
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 |
|---|---|---|
| 0718T | Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilateral | New Hampshire Precertification List, Pg 69 Original policy |
| 0720T | Percutaneous electrical nerve field stimulation, cranial nerves, without implantation | New Hampshire Precertification List, Pg 69 Original policy |
| 0736T | Colonic lavage, 35 or more liters of water, gravity-fed, with induced defecation, including insertion of rectal catheter | New Hampshire Precertification List, Pg 69 Original policy |
| 0738T | Treatment planning for magnetic field induction ablation of malignant prostate tissue, using data from previously performed magnetic resonance imaging (MRI) examination | New Hampshire Precertification List, Pg 69 Original policy |
| 0739T | Ablation of malignant prostate tissue by magnetic field induction, including all intraprocedural, transperineal needle/catheter placement for nanoparticle installation and intraprocedural temperature monitoring, thermal dosimetry, bladder irrigation, and magnetic field nanoparticle activation | New Hampshire Precertification List, Pg 69 Original policy |
| 0742T | Absolute Quantitation of Myocardial Blood Flow (AQMBF), single-photon Emission computed tomography (Spect), with exercis | New Hampshire Precertification List, Pg 69 Original policy |
| 0745T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image data (eg, CT, MRI, or myocardial perfusion scan) and electrical data (eg, 12-lead ECG data), and identification of areas of avoidance | New Hampshire Precertification List, Pg 70 Original policy |
| 0746T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiation treatment plan | New Hampshire Precertification List, Pg 70 Original policy |
| 0747T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia | New Hampshire Precertification List, Pg 70 Original policy |
| 0748T | Injections of stem cell product into perianal perifistular soft tissue, including fistula preparation (eg, removal of setons, fistula curettage, closure of internal openings) | New Hampshire Precertification List, Pg 70 Original policy |
| 0766T | Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, with identification and marking of the treatment location, including noninvasive electroneurographic localization (nerve conduction localization), when performed; first nerve | New Hampshire Precertification List, Pg 70 Original policy |
| 0767T | Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, with identification and marking of the treatment location, including noninvasive electroneurographic localization (nerve conduction localization), when performed; each additional nerve (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 70 Original policy |
| 0770T | Virtual reality technology to assist therapy (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 70 Original policy |
| 0771T | Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of dissociation or consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older | New Hampshire Precertification List, Pg 71 Original policy |
| 0772T | Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of dissociation or consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service) | New Hampshire Precertification List, Pg 71 Original policy |
| 0773T | Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; initial 15 minutes of intraservice time, patient age 5 years or older | New Hampshire Precertification List, Pg 71 Original policy |
| 0774T | Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service) | New Hampshire Precertification List, Pg 71 Original policy |
| 0778T | Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscle function | New Hampshire Precertification List, Pg 71 Original policy |
| 0783T | Transcutaneous auricular neurostimulation, set-up, calibration, and patient education on use of equipment | New Hampshire Precertification List, Pg 72 Original policy |
| 0786T | Insertion or replacement of percutaneous electrode array, sacral, with integrated neurostimulator, including imaging guidance, when performed | New Hampshire Precertification List, Pg 72 Original policy |
| 0787T | Revision or removal of neurostimulator electrode array, sacral, with integrated neurostimulator | New Hampshire Precertification List, Pg 72 Original policy |
| 0790T | Revision (eg, augmentation, division of tether), replacement, or removal of thoracolumbar or lumbar vertebral body tethering, including thoracoscopy, when performed | New Hampshire Precertification List, Pg 72 Original policy |
| 0795T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; complete system (ie, right atrial and right ventricular pacemaker components) | New Hampshire Precertification List, Pg 72 Original policy |
| 0796T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right atrial pacemaker component (when an existing right ventricular single leadless pacemaker exists to create a dual- chamber leadless pacemaker system) | New Hampshire Precertification List, Pg 72 Original policy |
| 0797T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right ventricular pacemaker component (when part of a dual-chamber leadless pacemaker system) | New Hampshire Precertification List, Pg 72 Original policy |
| 0798T | Transcatheter removal of permanent dual- chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography), when performed; complete system (ie, right atrial and right ventricular pacemaker components) | New Hampshire Precertification List, Pg 73 Original policy |
| 0799T | Transcatheter removal of permanent dual- chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography), when performed; right atrial pacemaker component | New Hampshire Precertification List, Pg 73 Original policy |
| 0800T | Transcatheter removal of permanent dual- chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography), when performed; right ventricular pacemaker component (when part of a dual-chamber leadless pacemaker system) | New Hampshire Precertification List, Pg 73 Original policy |
| 0801T | Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; dual- chamber system (ie, right atrial and right ventricular pacemaker components) | New Hampshire Precertification List, Pg 73 Original policy |
| 0802T | Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right atrial pacemaker component | New Hampshire Precertification List, Pg 73 Original policy |
| 0803T | Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right ventricular pacemaker component (when part of a dual-chamber leadless pacemaker system) | New Hampshire Precertification List, Pg 74 Original policy |
| 0804T | Programming device evaluation (in person) with iterative adjustment of implantable device to test the function of device and to select optimal permanent programmed values, with analysis, review, and report, by a physician or other qualified health care professional, leadless pacemaker system in dual cardiac chambers | New Hampshire Precertification List, Pg 74 Original policy |
| 0810T | Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies | New Hampshire Precertification List, Pg 74 Original policy |
| 0813T | Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of intragastric bariatric balloon | New Hampshire Precertification List, Pg 74 Original policy |
| 0816T | Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (eg, array or leadless), and pulse generator or receiver, including analysis, programming, and imaging guidance, when performed, posterior tibial nerve; subcutaneous | New Hampshire Precertification List, Pg 74 Original policy |
| 0817T | Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (eg, array or leadless), and pulse generator or receiver, including analysis, programming, and imaging guidance, when performed, posterior tibial nerve; subfascial | New Hampshire Precertification List, Pg 74 Original policy |
| 0818T | Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subcutaneous | New Hampshire Precertification List, Pg 74 Original policy |
| 0819T | Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subfascial | New Hampshire Precertification List, Pg 74 Original policy |
| 0823T | Transcatheter insertion of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography) and device evaluation (eg, interrogation or programming), when performed | New Hampshire Precertification List, Pg 75 Original policy |
| 0824T | Transcatheter removal of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography), when performed | New Hampshire Precertification List, Pg 75 Original policy |
| 0825T | Transcatheter removal and replacement of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography) and device evaluation (eg, interrogation or programming), when performed | New Hampshire Precertification List, Pg 75 Original policy |
| 0861T | Removal of pulse generator for wireless cardiac stimulator for left ventricular pacing; both components (battery and transmitter) | New Hampshire Precertification List, Pg 75 Original policy |
| 0862T | Relocation of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; battery component only | New Hampshire Precertification List, Pg 75 Original policy |
| 0863T | Relocation of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; transmitter component only | New Hampshire Precertification List, Pg 75 Original policy |
| 0864T | Low-intensity extracorporeal shock wave therapy involving corpus cavernosum, low energy | New Hampshire Precertification List, Pg 75 Original policy |
| 0888T | Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including imaging guidance | New Hampshire Precertification List, Pg 75 Original policy |
| 0890T | Accelerated, repetitive high-dose functional connectivity MRI-guided theta- burst stimulation, including target assessment, initial motor threshold determination, neuronavigati | New Hampshire Precertification List, Pg 75 Original policy |
| 0891T | Accelerated, repetitive high-dose functional connectivity MRI-guided theta- burst stimulation, including neuronavigation, delivery and management, subsequent treatment day | New Hampshire Precertification List, Pg 76 Original policy |
| 0892T | Accelerated, repetitive high-dose functional connectivity MRI-guided theta- burst stimulation, including neuronavigation, delivery and management, subsequent motor threshold re | New Hampshire Precertification List, Pg 76 Original policy |
| 0894T | Cannulation of the liver allograft in preparation for connection to the normothermic perfusion device and decannulation of the liver allograft following normothermic perfusion | New Hampshire Precertification List, Pg 76 Original policy |