Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 16
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 |
|---|---|---|
| 14040 | Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less | New Hampshire Precertification List, Pg 79 Original policy |
| 14041 | Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm | New Hampshire Precertification List, Pg 79 Original policy |
| 14060 | Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less | New Hampshire Precertification List, Pg 79 Original policy |
| 14061 | Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm | New Hampshire Precertification List, Pg 79 Original policy |
| 15011 | Harvest of skin for skin cell suspension autograft; first 25 sq cm or less | New Hampshire Precertification List, Pg 79 Original policy |
| 15013 | Preparation of skin cell suspension autograft, requiring enzymatic processing, manual mechanical disaggregation of skin cells, and filtration; first 25 sq cm or less of harvested skin | New Hampshire Precertification List, Pg 79 Original policy |
| 15015 | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, trunk, arms, legs; first 480 sq cm or less | New Hampshire Precertification List, Pg 80 Original policy |
| 15017 | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 480 sq cm or less | New Hampshire Precertification List, Pg 80 Original policy |
| 15150 | Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less | New Hampshire Precertification List, Pg 80 Original policy |
| 15155 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less | New Hampshire Precertification List, Pg 80 Original policy |
| 15271 | Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | New Hampshire Precertification List, Pg 80 Original policy |
| 15273 | Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | New Hampshire Precertification List, Pg 80 Original policy |
| 15275 | 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; first 25 sq cm or less wound surface area | New Hampshire Precertification List, Pg 80 Original policy |
| 15277 | 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; first 100 sq cm wound surface area, or 1% of body area of infants and children | New Hampshire Precertification List, Pg 80 Original policy |
| 15756 | Free muscle or myocutaneous flap with microvascular anastomosis | New Hampshire Precertification List, Pg 80 Original policy |
| 15771 | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate | New Hampshire Precertification List, Pg 80 Original policy |
| 15773 | Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate | New Hampshire Precertification List, Pg 80 Original policy |
| 15775 | Punch graft for hair transplant; 1 to 15 punch grafts | New Hampshire Precertification List, Pg 80 Original policy |
| 15776 | Punch graft for hair transplant; more than 15 punch grafts | New Hampshire Precertification List, Pg 80 Original policy |
| 15780 | Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) | New Hampshire Precertification List, Pg 81 Original policy |
| 15781 | Dermabrasion; segmental, face | New Hampshire Precertification List, Pg 81 Original policy |
| 15782 | Dermabrasion; regional, other than face | New Hampshire Precertification List, Pg 81 Original policy |
| 15783 | Dermabrasion; superficial, any site (eg, tattoo removal) | New Hampshire Precertification List, Pg 81 Original policy |
| 15786 | Abrasion; single lesion (eg, keratosis, scar) | New Hampshire Precertification List, Pg 81 Original policy |
| 15788 | Chemical peel, facial; epidermal | New Hampshire Precertification List, Pg 81 Original policy |
| 15789 | Chemical peel, facial; dermal | New Hampshire Precertification List, Pg 81 Original policy |
| 15792 | Chemical peel, nonfacial; epidermal | New Hampshire Precertification List, Pg 81 Original policy |
| 15793 | Chemical peel, nonfacial; dermal | New Hampshire Precertification List, Pg 81 Original policy |
| 15820 | Blepharoplasty, lower eyelid | New Hampshire Precertification List, Pg 81 Original policy |
| 15821 | Blepharoplasty, lower eyelid; with extensive herniated fat pad | New Hampshire Precertification List, Pg 81 Original policy |
| 15822 | Blepharoplasty, upper eyelid | New Hampshire Precertification List, Pg 81 Original policy |
| 15823 | Blepharoplasty, upper eyelid; with excessive skin weighting down lid | New Hampshire Precertification List, Pg 81 Original policy |
| 15824 | Rhytidectomy; forehead | New Hampshire Precertification List, Pg 81 Original policy |
| 15825 | Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) | New Hampshire Precertification List, Pg 81 Original policy |
| 15826 | Rhytidectomy; glabellar frown lines | New Hampshire Precertification List, Pg 81 Original policy |
| 15828 | Rhytidectomy; cheek, chin, and neck | New Hampshire Precertification List, Pg 81 Original policy |
| 15829 | Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap | New Hampshire Precertification List, Pg 81 Original policy |
| 15830 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy | New Hampshire Precertification List, Pg 81 Original policy |
| 15832 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh | New Hampshire Precertification List, Pg 81 Original policy |
| 15833 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg | New Hampshire Precertification List, Pg 81 Original policy |
| 15834 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip | New Hampshire Precertification List, Pg 81 Original policy |
| 15835 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock | New Hampshire Precertification List, Pg 81 Original policy |
| 15836 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm | New Hampshire Precertification List, Pg 81 Original policy |
| 15837 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand | New Hampshire Precertification List, Pg 82 Original policy |
| 15838 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad | New Hampshire Precertification List, Pg 82 Original policy |
| 15839 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area | New Hampshire Precertification List, Pg 82 Original policy |
| 15840 | Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) | New Hampshire Precertification List, Pg 82 Original policy |
| 15841 | Graft for facial nerve paralysis; free muscle graft (including obtaining graft) | New Hampshire Precertification List, Pg 82 Original policy |
| 15842 | Graft for facial nerve paralysis; free muscle flap by microsurgical technique | New Hampshire Precertification List, Pg 82 Original policy |
| 15845 | Graft for facial nerve paralysis; regional muscle transfer | New Hampshire Precertification List, Pg 82 Original policy |