Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 18
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 |
|---|---|---|
| 21073 | Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care) | New Hampshire Precertification List, Pg 85 Original policy |
| 21083 | Impression and custom preparation; palatal lift prosthesis | New Hampshire Precertification List, Pg 85 Original policy |
| 21086 | Impression and custom preparation; auricular prosthesis | New Hampshire Precertification List, Pg 85 Original policy |
| 21087 | Impression and custom preparation; nasal prosthesis | New Hampshire Precertification List, Pg 85 Original policy |
| 21110 | Application of interdental fixation device for conditions other than fracture or dislocation, includes removal | New Hampshire Precertification List, Pg 85 Original policy |
| 21116 | Injection procedure for temporomandibular joint arthrography | New Hampshire Precertification List, Pg 85 Original policy |
| 21120 | Genioplasty; augmentation (autograft, allograft, prosthetic material) | New Hampshire Precertification List, Pg 85 Original policy |
| 21121 | Genioplasty; sliding osteotomy, single piece | New Hampshire Precertification List, Pg 85 Original policy |
| 21122 | Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) | New Hampshire Precertification List, Pg 85 Original policy |
| 21123 | Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) | New Hampshire Precertification List, Pg 86 Original policy |
| 21125 | Augmentation, mandibular body or angle; prosthetic material | New Hampshire Precertification List, Pg 86 Original policy |
| 21127 | Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) | New Hampshire Precertification List, Pg 86 Original policy |
| 21137 | Reduction forehead; contouring only | New Hampshire Precertification List, Pg 86 Original policy |
| 21138 | Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) | New Hampshire Precertification List, Pg 86 Original policy |
| 21139 | Reduction forehead; contouring and setback of anterior frontal sinus wall | New Hampshire Precertification List, Pg 86 Original policy |
| 21141 | Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft | New Hampshire Precertification List, Pg 86 Original policy |
| 21142 | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft | New Hampshire Precertification List, Pg 86 Original policy |
| 21143 | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft | New Hampshire Precertification List, Pg 86 Original policy |
| 21145 | Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) | New Hampshire Precertification List, Pg 86 Original policy |
| 21146 | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) | New Hampshire Precertification List, Pg 86 Original policy |
| 21147 | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) | New Hampshire Precertification List, Pg 86 Original policy |
| 21150 | Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) | New Hampshire Precertification List, Pg 86 Original policy |
| 21151 | Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts) | New Hampshire Precertification List, Pg 86 Original policy |
| 21154 | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I | New Hampshire Precertification List, Pg 86 Original policy |
| 21155 | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I | New Hampshire Precertification List, Pg 86 Original policy |
| 21159 | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I | New Hampshire Precertification List, Pg 87 Original policy |
| 21160 | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I | New Hampshire Precertification List, Pg 87 Original policy |
| 21172 | Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) | New Hampshire Precertification List, Pg 87 Original policy |
| 21175 | Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) | New Hampshire Precertification List, Pg 87 Original policy |
| 21179 | Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) | New Hampshire Precertification List, Pg 87 Original policy |
| 21180 | Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) | New Hampshire Precertification List, Pg 87 Original policy |
| 21182 | Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm | New Hampshire Precertification List, Pg 87 Original policy |
| 21183 | Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 40 sq cm but less than 80 sq cm | New Hampshire Precertification List, Pg 87 Original policy |
| 21184 | Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 80 sq cm | New Hampshire Precertification List, Pg 87 Original policy |
| 21188 | Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) | New Hampshire Precertification List, Pg 87 Original policy |
| 21193 | Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft | New Hampshire Precertification List, Pg 88 Original policy |
| 21194 | Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) | New Hampshire Precertification List, Pg 88 Original policy |
| 21195 | Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation | New Hampshire Precertification List, Pg 88 Original policy |
| 21196 | Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation | New Hampshire Precertification List, Pg 88 Original policy |
| 21198 | Osteotomy, mandible, segmental | New Hampshire Precertification List, Pg 88 Original policy |
| 21199 | Osteotomy, mandible, segmental; with genioglossus advancement | New Hampshire Precertification List, Pg 88 Original policy |
| 21206 | Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) | New Hampshire Precertification List, Pg 88 Original policy |
| 21208 | Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) | New Hampshire Precertification List, Pg 88 Original policy |
| 21209 | Osteoplasty, facial bones; reduction | New Hampshire Precertification List, Pg 88 Original policy |
| 21210 | Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) | New Hampshire Precertification List, Pg 88 Original policy |
| 21215 | Graft, bone; mandible (includes obtaining graft) | New Hampshire Precertification List, Pg 88 Original policy |
| 21230 | Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) | New Hampshire Precertification List, Pg 88 Original policy |
| 21235 | Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) | New Hampshire Precertification List, Pg 88 Original policy |
| 21240 | Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) | New Hampshire Precertification List, Pg 88 Original policy |
| 21242 | Arthroplasty, temporomandibular joint, with allograft | New Hampshire Precertification List, Pg 88 Original policy |