Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 15
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 |
|---|---|---|
| 0895T | Connection of liver allograft to normothermic machine perfusion device, hemostasis control; initial 4 hours of monitoring time, including hourly physiological and laboratory assessments (eg, perfusate temperature, perfusate pH, hemodynamic parameters, bile production, bile pH, bile glucose, biliary bicarbonate, lactate levels, macroscopic assessment) | New Hampshire Precertification List, Pg 76 Original policy |
| 0899T | Noninvasive Determination of absolute quantitation of myocardial blood flow (AQMBF) derived from augmentative algorithmic | New Hampshire Precertification List, Pg 76 Original policy |
| 0900T | Noninvasive Determination of absolute quantitation of myocardial blood flow (AQMBF) derived from assistive algorithmic | New Hampshire Precertification List, Pg 76 Original policy |
| 0908T | Open implantation of integrated neurostim | New Hampshire Precertification List, Pg 76 Original policy |
| 0909T | Replacement of integrated neurostimulatio | New Hampshire Precertification List, Pg 76 Original policy |
| 0910T | Removal of integrated neurostimulation sy | New Hampshire Precertification List, Pg 76 Original policy |
| 0911T | Electronic analysis of implanted integrated | New Hampshire Precertification List, Pg 76 Original policy |
| 0912T | Electronic analysis of implanted integrated | New Hampshire Precertification List, Pg 76 Original policy |
| 0913T | Percutaneous transcatheter therapeutic dr | New Hampshire Precertification List, Pg 76 Original policy |
| 0915T | Insertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and ther | New Hampshire Precertification List, Pg 76 Original policy |
| 0916T | Insertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and ther | New Hampshire Precertification List, Pg 76 Original policy |
| 0917T | Insertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and ther | New Hampshire Precertification List, Pg 77 Original policy |
| 0918T | Insertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and ther | New Hampshire Precertification List, Pg 77 Original policy |
| 0919T | Removal of a permanent cardiac contractility modulation-defibrillation system component(s); pulse generator only | New Hampshire Precertification List, Pg 77 Original policy |
| 0920T | Removal of a permanent cardiac contractility modulation-defibrillation system component(s); single transvenous pacing lead only | New Hampshire Precertification List, Pg 77 Original policy |
| 0921T | Removal of a permanent cardiac contractility modulation-defibrillation system component(s); single transvenous defibrillation lead only | New Hampshire Precertification List, Pg 77 Original policy |
| 0922T | Removal of a permanent cardiac contractility modulation-defibrillation system component(s); dual (pacing and defibrillation) transvenous leads only | New Hampshire Precertification List, Pg 77 Original policy |
| 0923T | Removal and replacement of permanent cardiac contractility modulationdefibrillation pulse generator only | New Hampshire Precertification List, Pg 77 Original policy |
| 0924T | Repositioning of previously implanted cardiac contractility modulation- defibrillation transvenous electrode(s)/lead(s), including fluoroscopic guidance and programming of sens | New Hampshire Precertification List, Pg 77 Original policy |
| 0925T | Relocation of skin pocket for implanted cardiac contractility modulation- defibrillation pulse generator | New Hampshire Precertification List, Pg 77 Original policy |
| 0926T | Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values | New Hampshire Precertification List, Pg 77 Original policy |
| 0927T | Interrogation device evaluation (in person) with analysis, review, and report, including connection, recording, and disconnection, per patient encounter, implantable cardiac c | New Hampshire Precertification List, Pg 77 Original policy |
| 0928T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation-defibrillation system with interim analysis and report(s) by a physician or other qua | New Hampshire Precertification List, Pg 77 Original policy |
| 0929T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation-defibrillation system, remote data acquisition(s), receipt of transmissions, technici | New Hampshire Precertification List, Pg 78 Original policy |
| 0930T | Electrophysiologic evaluation of cardiac contractility modulation-defibrillator leads, including defibrillation-threshold evaluation (induction of arrhythmia, evaluation of se | New Hampshire Precertification List, Pg 78 Original policy |
| 0931T | Electrophysiologic evaluation of cardiac contractility modulation-defibrillator leads, including defibrillation-threshold evaluation (induction of arrhythmia, evaluation of se | New Hampshire Precertification List, Pg 78 Original policy |
| 0933T | Transcatheter implantation of wireless left atrial pressure sensor for long-term left atrial pressure monitoring, including sensor calibration and deployment, right heart cath | New Hampshire Precertification List, Pg 78 Original policy |
| 0934T | Remote monitoring of a wireless left atrial pressure sensor for up to 30 days, including data from daily uploads of left atrial pressure recordings, interpretation(s) and tren | New Hampshire Precertification List, Pg 78 Original policy |
| 0935T | Cystourethroscopy with renal pelvic sympathetic denervation, radiofrequency ablation, retrograde ureteral approach, including insertion of guide wire, selective placement | New Hampshire Precertification List, Pg 78 Original policy |
| 0948T | Interrogation device evaluation (remote), u | New Hampshire Precertification List, Pg 78 Original policy |
| 0949T | Interrogation device evaluation (remote), u | New Hampshire Precertification List, Pg 78 Original policy |
| 0951T | Totally implantable active middle ear hearing implant; initial placement, including mastoidectomy, placement of and attachment to sound processor | New Hampshire Precertification List, Pg 78 Original policy |
| 0952T | Totally implantable active middle ear hearing implant; revision or replacement, with mastoidectomy and replacement of sound processor | New Hampshire Precertification List, Pg 78 Original policy |
| 0953T | Totally implantable active middle ear hearing implant; replacement of sound processor only, with attachment to existing transducers | New Hampshire Precertification List, Pg 78 Original policy |
| 0954T | Totally implantable active middle ear hearing implant; replacement of sound processor only, with attachment to existing transducers | New Hampshire Precertification List, Pg 78 Original policy |
| 0955T | Totally implantable active middle ear hearing implant; removal, including removal of sound processor and all implant components | New Hampshire Precertification List, Pg 78 Original policy |
| 0964T | Impression and custom preparation of jaw | New Hampshire Precertification List, Pg 78 Original policy |
| 0965T | Impression and custom preparation of jaw | New Hampshire Precertification List, Pg 78 Original policy |
| 0966T | Impression and custom preparation of jaw | New Hampshire Precertification List, Pg 79 Original policy |
| 0970T | Ablation, benign breast tumor (eg, fibroadenoma), percutaneous, laser, including imaging guidance when performed, each tumor | New Hampshire Precertification List, Pg 79 Original policy |
| 0971T | Ablation, malignant breast tumor(s), percutaneous, laser, including imaging guidance when performed, unilateral | New Hampshire Precertification List, Pg 79 Original policy |
| 0978T | Submucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil | New Hampshire Precertification List, Pg 79 Original policy |
| 0979T | Submucosal cryolysis therapy; soft palate only | New Hampshire Precertification List, Pg 79 Original policy |
| 0980T | Submucosal cryolysis therapy; base of tongue and lingual tonsil only | New Hampshire Precertification List, Pg 79 Original policy |
| 11920 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less | New Hampshire Precertification List, Pg 79 Original policy |
| 11921 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm | New Hampshire Precertification List, Pg 79 Original policy |
| 11950 | Subcutaneous injection of filling material (eg, collagen); 1 cc or less | New Hampshire Precertification List, Pg 79 Original policy |
| 11951 | Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc | New Hampshire Precertification List, Pg 79 Original policy |
| 11952 | Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc | New Hampshire Precertification List, Pg 79 Original policy |
| 11954 | Subcutaneous injection of filling material (eg, collagen); over 10.0 cc | New Hampshire Precertification List, Pg 79 Original policy |