Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 17
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 |
|---|---|---|
| 15876 | Suction assisted lipectomy; head and neck | New Hampshire Precertification List, Pg 82 Original policy |
| 15877 | Suction assisted lipectomy; trunk | New Hampshire Precertification List, Pg 82 Original policy |
| 15878 | Suction assisted lipectomy; upper extremity | New Hampshire Precertification List, Pg 82 Original policy |
| 15879 | Suction assisted lipectomy; lower extremity | New Hampshire Precertification List, Pg 82 Original policy |
| 17106 | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm | New Hampshire Precertification List, Pg 82 Original policy |
| 17107 | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm | New Hampshire Precertification List, Pg 82 Original policy |
| 17108 | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm | New Hampshire Precertification List, Pg 82 Original policy |
| 17380 | Electrolysis epilation, each 30 minutes | New Hampshire Precertification List, Pg 82 Original policy |
| 19105 | Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma | New Hampshire Precertification List, Pg 82 Original policy |
| 19296 | Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy | New Hampshire Precertification List, Pg 82 Original policy |
| 19298 | Placement of radiotherapy after loading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance | New Hampshire Precertification List, Pg 82 Original policy |
| 19300 | Mastectomy for gynecomastia | New Hampshire Precertification List, Pg 82 Original policy |
| 19303 | Mastectomy , simple, complete | New Hampshire Precertification List, Pg 83 Original policy |
| 19316 | Mastopexy | New Hampshire Precertification List, Pg 83 Original policy |
| 19318 | Breast reduction | New Hampshire Precertification List, Pg 83 Original policy |
| 19325 | Breast augmentation with implant | New Hampshire Precertification List, Pg 83 Original policy |
| 19328 | Removal of intact breast implant | New Hampshire Precertification List, Pg 83 Original policy |
| 19330 | Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel) | New Hampshire Precertification List, Pg 83 Original policy |
| 19340 | Insertion of breast implant on same day of mastectomy (ie, immediate) | New Hampshire Precertification List, Pg 83 Original policy |
| 19342 | Insertion or replacement of breast implant on separate day from mastectomy | New Hampshire Precertification List, Pg 83 Original policy |
| 19350 | Nipple/areola reconstruction | New Hampshire Precertification List, Pg 83 Original policy |
| 19355 | Correction of inverted nipples | New Hampshire Precertification List, Pg 83 Original policy |
| 19357 | Tissue expander placement in breast reconstruction, including subsequent expansion(s) | New Hampshire Precertification List, Pg 83 Original policy |
| 19361 | Breast reconstruction; with latissimus dorsi flap | New Hampshire Precertification List, Pg 83 Original policy |
| 19364 | Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap) | New Hampshire Precertification List, Pg 83 Original policy |
| 19367 | Breast reconstruction; with single- pedicled transverse rectus abdominis myocutaneous (TRAM) flap | New Hampshire Precertification List, Pg 83 Original policy |
| 19368 | Breast reconstruction; with single- pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging) | New Hampshire Precertification List, Pg 83 Original policy |
| 19369 | Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap | New Hampshire Precertification List, Pg 83 Original policy |
| 19380 | Revision of reconstructed breast (eg, significant removal of tissue, re- advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction) | New Hampshire Precertification List, Pg 83 Original policy |
| 19396 | Preparation of moulage for custom breast implant | New Hampshire Precertification List, Pg 83 Original policy |
| 20555 | Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure) | New Hampshire Precertification List, Pg 83 Original policy |
| 20560 | Needle insertion(s) without injection(s); 1 or 2 muscle(s) | New Hampshire Precertification List, Pg 84 Original policy |
| 20561 | Needle insertion(s) without injection(s); 3 or more muscles | New Hampshire Precertification List, Pg 84 Original policy |
| 20605 | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance | New Hampshire Precertification List, Pg 84 Original policy |
| 20606 | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting | New Hampshire Precertification List, Pg 84 Original policy |
| 20930 | Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 84 Original policy |
| 20931 | Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 84 Original policy |
| 20932 | Allograft, includes templating, cutting, placement and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 84 Original policy |
| 20933 | Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (ie, hemicylindrical) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 84 Original policy |
| 20934 | Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (ie, cylindrical) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 84 Original policy |
| 20936 | Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 84 Original policy |
| 20937 | Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 84 Original policy |
| 20938 | Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 85 Original policy |
| 20974 | Electrical stimulation to aid bone healing; noninvasive (nonoperative) | New Hampshire Precertification List, Pg 85 Original policy |
| 20979 | Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) | New Hampshire Precertification List, Pg 85 Original policy |
| 20982 | Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency | New Hampshire Precertification List, Pg 85 Original policy |
| 20983 | Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation | New Hampshire Precertification List, Pg 85 Original policy |
| 21010 | Arthrotomy, temporomandibular joint | New Hampshire Precertification List, Pg 85 Original policy |
| 21050 | Condylectomy, temporomandibular joint (separate procedure) | New Hampshire Precertification List, Pg 85 Original policy |
| 21060 | Meniscectomy, partial or complete, temporomandibular joint (separate procedure) | New Hampshire Precertification List, Pg 85 Original policy |