Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 21
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 |
|---|---|---|
| 23412 | Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic | New Hampshire Precertification List, Pg 97 Original policy |
| 23415 | Coracoacromial ligament release, with or without acromioplasty | New Hampshire Precertification List, Pg 97 Original policy |
| 23420 | Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) | New Hampshire Precertification List, Pg 97 Original policy |
| 23430 | Tenodesis of long tendon of biceps | New Hampshire Precertification List, Pg 97 Original policy |
| 23440 | Resection or transplantation of long tendon of biceps | New Hampshire Precertification List, Pg 97 Original policy |
| 23450 | Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation | New Hampshire Precertification List, Pg 97 Original policy |
| 23455 | Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure) | New Hampshire Precertification List, Pg 97 Original policy |
| 23460 | Capsulorrhaphy, anterior, any type; with bone block | New Hampshire Precertification List, Pg 97 Original policy |
| 23462 | Capsulorrhaphy, anterior, any type; with coracoid process transfer | New Hampshire Precertification List, Pg 97 Original policy |
| 23465 | Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block | New Hampshire Precertification List, Pg 97 Original policy |
| 23466 | Capsulorrhaphy, glenohumeral joint, any type multi-directional instability | New Hampshire Precertification List, Pg 97 Original policy |
| 23470 | Arthroplasty, glenohumeral joint; hemiarthroplasty | New Hampshire Precertification List, Pg 97 Original policy |
| 23472 | Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) | New Hampshire Precertification List, Pg 97 Original policy |
| 23473 | Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component | New Hampshire Precertification List, Pg 97 Original policy |
| 23474 | Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component | New Hampshire Precertification List, Pg 97 Original policy |
| 23700 | Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) | New Hampshire Precertification List, Pg 97 Original policy |
| 24300 | Manipulation, elbow, under anesthesia | New Hampshire Precertification List, Pg 97 Original policy |
| 25259 | Manipulation, wrist, under anesthesia | New Hampshire Precertification List, Pg 97 Original policy |
| 26340 | Manipulation, finger joint, under anesthesia, each joint | New Hampshire Precertification List, Pg 97 Original policy |
| 27096 | Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed | New Hampshire Precertification List, Pg 97 Original policy |
| 27120 | Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type) | New Hampshire Precertification List, Pg 97 Original policy |
| 27122 | Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure) | New Hampshire Precertification List, Pg 97 Original policy |
| 27125 | Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) | New Hampshire Precertification List, Pg 98 Original policy |
| 27130 | Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft | New Hampshire Precertification List, Pg 98 Original policy |
| 27132 | Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft | New Hampshire Precertification List, Pg 98 Original policy |
| 27134 | Revision of total hip arthroplasty; both components, with or without autograft or allograft | New Hampshire Precertification List, Pg 98 Original policy |
| 27137 | Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft | New Hampshire Precertification List, Pg 98 Original policy |
| 27138 | Revision of total hip arthroplasty; femoral component only, with or without allograft | New Hampshire Precertification List, Pg 98 Original policy |
| 27275 | Manipulation, hip joint, requiring general anesthesia | New Hampshire Precertification List, Pg 98 Original policy |
| 27279 | Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixation device | New Hampshire Precertification List, Pg 98 Original policy |
| 27331 | Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies | New Hampshire Precertification List, Pg 98 Original policy |
| 27332 | Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral | New Hampshire Precertification List, Pg 98 Original policy |
| 27333 | Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral | New Hampshire Precertification List, Pg 98 Original policy |
| 27334 | Arthrotomy, with synovectomy, knee; anterior OR posterior | New Hampshire Precertification List, Pg 98 Original policy |
| 27335 | Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area | New Hampshire Precertification List, Pg 98 Original policy |
| 27345 | Excision of synovial cyst of popliteal space (eg, Baker's cyst) | New Hampshire Precertification List, Pg 98 Original policy |
| 27403 | Arthrotomy with meniscus repair, knee | New Hampshire Precertification List, Pg 98 Original policy |
| 27405 | Repair, primary, torn ligament and/or capsule, knee; collateral | New Hampshire Precertification List, Pg 98 Original policy |
| 27407 | Repair, primary, torn ligament and/or capsule, knee; cruciate | New Hampshire Precertification List, Pg 98 Original policy |
| 27409 | Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments | New Hampshire Precertification List, Pg 98 Original policy |
| 27412 | Autologous chondrocyte implantation, knee | New Hampshire Precertification List, Pg 98 Original policy |
| 27415 | Osteochondral allograft, knee, open | New Hampshire Precertification List, Pg 98 Original policy |
| 27416 | Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) | New Hampshire Precertification List, Pg 99 Original policy |
| 27425 | Lateral retinacular release, open | New Hampshire Precertification List, Pg 99 Original policy |
| 27427 | Ligamentous reconstruction (augmentation), knee; extra-articular | New Hampshire Precertification List, Pg 99 Original policy |
| 27428 | Ligamentous reconstruction (augmentation), knee; intra-articular (open) | New Hampshire Precertification List, Pg 99 Original policy |
| 27429 | Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular | New Hampshire Precertification List, Pg 99 Original policy |
| 27437 | Arthroplasty, patella; without prosthesis | New Hampshire Precertification List, Pg 99 Original policy |
| 27438 | Arthroplasty, patella; with prosthesis | New Hampshire Precertification List, Pg 99 Original policy |
| 27440 | Arthroplasty, knee, tibial plateau | New Hampshire Precertification List, Pg 99 Original policy |