Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 20
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 |
|---|---|---|
| 22610 | Arthrodesis, posterior or posterolateral technique, single interspace; thoracic (with lateral transverse technique, when performed) | New Hampshire Precertification List, Pg 92 Original policy |
| 22612 | Arthrodesis, posterior or posterolateral technique, single interspace; lumbar (with lateral transverse technique, when performed) | New Hampshire Precertification List, Pg 92 Original policy |
| 22614 | Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 92 Original policy |
| 22630 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar | New Hampshire Precertification List, Pg 92 Original policy |
| 22632 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar; each additional interspace (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 93 Original policy |
| 22633 | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace, lumbar | New Hampshire Precertification List, Pg 93 Original policy |
| 22634 | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace, lumbar; each additional interspace (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 93 Original policy |
| 22800 | Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments | New Hampshire Precertification List, Pg 93 Original policy |
| 22802 | Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments | New Hampshire Precertification List, Pg 93 Original policy |
| 22804 | Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments | New Hampshire Precertification List, Pg 93 Original policy |
| 22808 | Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments | New Hampshire Precertification List, Pg 93 Original policy |
| 22810 | Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments | New Hampshire Precertification List, Pg 93 Original policy |
| 22812 | Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments | New Hampshire Precertification List, Pg 93 Original policy |
| 22818 | Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments | New Hampshire Precertification List, Pg 93 Original policy |
| 22819 | Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments | New Hampshire Precertification List, Pg 93 Original policy |
| 22830 | Exploration of spinal fusion | New Hampshire Precertification List, Pg 93 Original policy |
| 22836 | Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; up to 7 vertebral segments | New Hampshire Precertification List, Pg 94 Original policy |
| 22837 | Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; 8 or more vertebral segments | New Hampshire Precertification List, Pg 94 Original policy |
| 22838 | Revision (eg, augmentation, division of tether), replacement, or removal of thoracic vertebral body tethering, including thoracoscopy, when performed | New Hampshire Precertification List, Pg 94 Original policy |
| 22840 | Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 94 Original policy |
| 22841 | Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 94 Original policy |
| 22842 | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 94 Original policy |
| 22843 | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 94 Original policy |
| 22844 | Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 94 Original policy |
| 22845 | Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 94 Original policy |
| 22846 | Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 94 Original policy |
| 22847 | Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 94 Original policy |
| 22848 | Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 94 Original policy |
| 22849 | Reinsertion of spinal fixation device | New Hampshire Precertification List, Pg 95 Original policy |
| 22852 | Removal of posterior segmental instrumentation | New Hampshire Precertification List, Pg 95 Original policy |
| 22853 | Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 95 Original policy |
| 22854 | Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 95 Original policy |
| 22856 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical | New Hampshire Precertification List, Pg 95 Original policy |
| 22857 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); single interspace, lumbar | New Hampshire Precertification List, Pg 95 Original policy |
| 22858 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 95 Original policy |
| 22859 | Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 95 Original policy |
| 22860 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 96 Original policy |
| 22861 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical | New Hampshire Precertification List, Pg 96 Original policy |
| 22862 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar | New Hampshire Precertification List, Pg 96 Original policy |
| 22864 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical | New Hampshire Precertification List, Pg 96 Original policy |
| 22865 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar | New Hampshire Precertification List, Pg 96 Original policy |
| 22867 | Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level | New Hampshire Precertification List, Pg 96 Original policy |
| 22868 | Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 96 Original policy |
| 22869 | Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level | New Hampshire Precertification List, Pg 96 Original policy |
| 22870 | Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 96 Original policy |
| 23105 | Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy | New Hampshire Precertification List, Pg 96 Original policy |
| 23107 | Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body | New Hampshire Precertification List, Pg 96 Original policy |
| 23120 | Claviculectomy; partial | New Hampshire Precertification List, Pg 96 Original policy |
| 23130 | Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release | New Hampshire Precertification List, Pg 96 Original policy |
| 23410 | Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute | New Hampshire Precertification List, Pg 97 Original policy |