Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 19
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 |
|---|---|---|
| 21243 | Arthroplasty, temporomandibular joint, with prosthetic joint replacement | New Hampshire Precertification List, Pg 88 Original policy |
| 21244 | Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) | New Hampshire Precertification List, Pg 88 Original policy |
| 21245 | Reconstruction of mandible or maxilla, subperiosteal implant; partial | New Hampshire Precertification List, Pg 88 Original policy |
| 21246 | Reconstruction of mandible or maxilla, subperiosteal implant; complete | New Hampshire Precertification List, Pg 88 Original policy |
| 21247 | Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia) | New Hampshire Precertification List, Pg 88 Original policy |
| 21255 | Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) | New Hampshire Precertification List, Pg 88 Original policy |
| 21256 | Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro- ophthalmia) | New Hampshire Precertification List, Pg 89 Original policy |
| 21270 | Malar augmentation, prosthetic material | New Hampshire Precertification List, Pg 89 Original policy |
| 21275 | Secondary revision of orbitocraniofacial reconstruction | New Hampshire Precertification List, Pg 89 Original policy |
| 21685 | Hyoid myotomy and suspension | New Hampshire Precertification List, Pg 89 Original policy |
| 21740 | Reconstructive repair of pectus excavatum or carinatum; open | New Hampshire Precertification List, Pg 89 Original policy |
| 21742 | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy | New Hampshire Precertification List, Pg 89 Original policy |
| 21743 | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy | New Hampshire Precertification List, Pg 89 Original policy |
| 21811 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs | New Hampshire Precertification List, Pg 89 Original policy |
| 21812 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs | New Hampshire Precertification List, Pg 89 Original policy |
| 21813 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 7 or more ribs | New Hampshire Precertification List, Pg 89 Original policy |
| 22206 | Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic | New Hampshire Precertification List, Pg 89 Original policy |
| 22207 | Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); lumbar | New Hampshire Precertification List, Pg 89 Original policy |
| 22208 | Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 89 Original policy |
| 22210 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical | New Hampshire Precertification List, Pg 89 Original policy |
| 22212 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic | New Hampshire Precertification List, Pg 89 Original policy |
| 22214 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar | New Hampshire Precertification List, Pg 89 Original policy |
| 22216 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (List separately in addition to primary procedure) | New Hampshire Precertification List, Pg 90 Original policy |
| 22220 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical | New Hampshire Precertification List, Pg 90 Original policy |
| 22222 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic | New Hampshire Precertification List, Pg 90 Original policy |
| 22224 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar | New Hampshire Precertification List, Pg 90 Original policy |
| 22226 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 90 Original policy |
| 22505 | Manipulation of spine requiring anesthesia, any region | New Hampshire Precertification List, Pg 90 Original policy |
| 22510 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic | New Hampshire Precertification List, Pg 90 Original policy |
| 22511 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral | New Hampshire Precertification List, Pg 90 Original policy |
| 22512 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 90 Original policy |
| 22513 | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic | New Hampshire Precertification List, Pg 90 Original policy |
| 22514 | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar | New Hampshire Precertification List, Pg 90 Original policy |
| 22515 | Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 91 Original policy |
| 22526 | Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level | New Hampshire Precertification List, Pg 91 Original policy |
| 22527 | Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 91 Original policy |
| 22532 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic | New Hampshire Precertification List, Pg 91 Original policy |
| 22533 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | New Hampshire Precertification List, Pg 91 Original policy |
| 22534 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 91 Original policy |
| 22548 | Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas- axis), with or without excision of odontoid process | New Hampshire Precertification List, Pg 91 Original policy |
| 22551 | Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 | New Hampshire Precertification List, Pg 91 Original policy |
| 22552 | Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure) | New Hampshire Precertification List, Pg 91 Original policy |
| 22554 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 | New Hampshire Precertification List, Pg 92 Original policy |
| 22556 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic | New Hampshire Precertification List, Pg 92 Original policy |
| 22558 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | New Hampshire Precertification List, Pg 92 Original policy |
| 22585 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 92 Original policy |
| 22586 | Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5- S1 interspace | New Hampshire Precertification List, Pg 92 Original policy |
| 22590 | Arthrodesis, posterior technique, craniocervical (occiput-C2) | New Hampshire Precertification List, Pg 92 Original policy |
| 22595 | Arthrodesis, posterior technique, atlas- axis (C1-C2) | New Hampshire Precertification List, Pg 92 Original policy |
| 22600 | Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment | New Hampshire Precertification List, Pg 92 Original policy |