Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 2
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 |
|---|---|---|
| 37238 | Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein | New Hampshire Precertification List, Pg 8 Original policy |
| 37239 | Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 8 Original policy |
| 37244 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation | New Hampshire Precertification List, Pg 8 Original policy |
| 37246 | Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; initial artery | New Hampshire Precertification List, Pg 8 Original policy |
| 37248 | Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein | New Hampshire Precertification List, Pg 9 Original policy |
| 37249 | Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 9 Original policy |
| 54410 | Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session | New Hampshire Precertification List, Pg 9 Original policy |
| 54411 | Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue | New Hampshire Precertification List, Pg 9 Original policy |
| 54416 | Removal and replacement of non- inflatable (semi-rigid) or inflatable (self- contained) penile prosthesis at the same operative session | New Hampshire Precertification List, Pg 9 Original policy |
| 54417 | Removal and replacement of non- inflatable (semi-rigid) or inflatable (self- contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue | New Hampshire Precertification List, Pg 9 Original policy |
| 55880 | Ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance | New Hampshire Precertification List, Pg 9 Original policy |
| 58145 | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach | New Hampshire Precertification List, Pg 9 Original policy |
| 58260 | Vaginal hysterectomy, for uterus 250 g or less | New Hampshire Precertification List, Pg 9 Original policy |
| 58262 | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s) | New Hampshire Precertification List, Pg 9 Original policy |
| 58263 | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele | New Hampshire Precertification List, Pg 9 Original policy |
| 58270 | Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele | New Hampshire Precertification List, Pg 9 Original policy |
| 58290 | Vaginal hysterectomy, for uterus greater than 250 g | New Hampshire Precertification List, Pg 9 Original policy |
| 58291 | Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) | New Hampshire Precertification List, Pg 10 Original policy |
| 58292 | Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele | New Hampshire Precertification List, Pg 10 Original policy |
| 58294 | Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele | New Hampshire Precertification List, Pg 10 Original policy |
| 58541 | Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less | New Hampshire Precertification List, Pg 10 Original policy |
| 58542 | Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) | New Hampshire Precertification List, Pg 10 Original policy |
| 58543 | Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g | New Hampshire Precertification List, Pg 10 Original policy |
| 58544 | Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) | New Hampshire Precertification List, Pg 10 Original policy |
| 58545 | Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas | New Hampshire Precertification List, Pg 10 Original policy |
| 58546 | Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g | New Hampshire Precertification List, Pg 10 Original policy |
| 58550 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less | New Hampshire Precertification List, Pg 10 Original policy |
| 58553 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g | New Hampshire Precertification List, Pg 10 Original policy |
| 61215 | Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter | New Hampshire Precertification List, Pg 10 Original policy |
| 61640 | Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel | New Hampshire Precertification List, Pg 10 Original policy |
| 61641 | Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in same vascular territory (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 10 Original policy |
| 61642 | Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different vascular territory (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 10 Original policy |
| 62350 | Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy | New Hampshire Precertification List, Pg 11 Original policy |
| 62351 | Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy | New Hampshire Precertification List, Pg 11 Original policy |
| 62360 | Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir | New Hampshire Precertification List, Pg 11 Original policy |
| 62361 | Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump | New Hampshire Precertification List, Pg 11 Original policy |
| 62362 | Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming | New Hampshire Precertification List, Pg 11 Original policy |
| 63052 | Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 11 Original policy |
| 63053 | Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional vertebral segment (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 11 Original policy |
| 64597 | Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; each additional electrode array (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 11 Original policy |
| 69705 | Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); unilateral | New Hampshire Precertification List, Pg 11 Original policy |
| 69706 | Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); bilateral | New Hampshire Precertification List, Pg 12 Original policy |
| 78434 | Absolute Quantitation of myocardial blood flow (AQMBF), position emission tomography (PET), rest and pharmacologic stress | New Hampshire Precertification List, Pg 12 Original policy |
| 89280 | Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes | New Hampshire Precertification List, Pg 12 Original policy |
| 89281 | Assisted oocyte fertilization, microtechnique; greater than 10 oocytes | New Hampshire Precertification List, Pg 12 Original policy |
| 89290 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre- implantation genetic diagnosis); less than or equal to 5 embryos | New Hampshire Precertification List, Pg 12 Original policy |
| 89291 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre- implantation genetic diagnosis); greater than 5 embryos | New Hampshire Precertification List, Pg 12 Original policy |
| 89337 | Cryopreservation, mature oocyte(s) | New Hampshire Precertification List, Pg 12 Original policy |
| 90382 | Respiratory syncytial virus, monoclonal an | New Hampshire Precertification List, Pg 12 Original policy |
| 92972 | Percutaneous transluminal coronary lithotripsy | New Hampshire Precertification List, Pg 12 Original policy |