Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 22
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 |
|---|---|---|
| 27441 | Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy | New Hampshire Precertification List, Pg 99 Original policy |
| 27442 | Arthroplasty, femoral condyles or tibial plateau(s), knee | New Hampshire Precertification List, Pg 99 Original policy |
| 27443 | Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy | New Hampshire Precertification List, Pg 99 Original policy |
| 27445 | Arthroplasty, knee, hinge prosthesis (eg, Walldius type) | New Hampshire Precertification List, Pg 99 Original policy |
| 27446 | Arthroplasty, knee, condyle and plateau; medial OR lateral compartment | New Hampshire Precertification List, Pg 99 Original policy |
| 27447 | Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) | New Hampshire Precertification List, Pg 99 Original policy |
| 27486 | Revision of total knee arthroplasty, with or without allograft; 1 component | New Hampshire Precertification List, Pg 99 Original policy |
| 27487 | Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component | New Hampshire Precertification List, Pg 99 Original policy |
| 27488 | Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee | New Hampshire Precertification List, Pg 99 Original policy |
| 27570 | Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices) | New Hampshire Precertification List, Pg 99 Original policy |
| 27702 | Arthroplasty, ankle; with implant (total ankle) | New Hampshire Precertification List, Pg 99 Original policy |
| 27703 | Arthroplasty, ankle; revision, total ankle | New Hampshire Precertification List, Pg 99 Original policy |
| 27704 | Removal of ankle implant | New Hampshire Precertification List, Pg 99 Original policy |
| 27860 | Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus) | New Hampshire Precertification List, Pg 100 Original policy |
| 27870 | Arthrodesis, ankle, open | New Hampshire Precertification List, Pg 100 Original policy |
| 28110 | Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure) | New Hampshire Precertification List, Pg 100 Original policy |
| 28285 | Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy) | New Hampshire Precertification List, Pg 100 Original policy |
| 28286 | Correction, cock-up fifth toe, with plastic skin closure (eg, Ruiz-Mora type procedure) | New Hampshire Precertification List, Pg 100 Original policy |
| 28289 | Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant | New Hampshire Precertification List, Pg 100 Original policy |
| 28291 | Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint with implant | New Hampshire Precertification List, Pg 100 Original policy |
| 28292 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with resection of proximal phalanx base, when performed, any method | New Hampshire Precertification List, Pg 100 Original policy |
| 28295 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal metatarsal osteotomy, any method | New Hampshire Precertification List, Pg 100 Original policy |
| 28296 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with distal metatarsal osteotomy, any method | New Hampshire Precertification List, Pg 100 Original policy |
| 28297 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method | New Hampshire Precertification List, Pg 100 Original policy |
| 28298 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal phalanx osteotomy, any method | New Hampshire Precertification List, Pg 100 Original policy |
| 28299 | Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with double osteotomy, any method | New Hampshire Precertification List, Pg 100 Original policy |
| 28306 | Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal | New Hampshire Precertification List, Pg 100 Original policy |
| 28307 | Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal with autograft (other than first toe) | New Hampshire Precertification List, Pg 100 Original policy |
| 28308 | Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each | New Hampshire Precertification List, Pg 101 Original policy |
| 28310 | Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure) | New Hampshire Precertification List, Pg 101 Original policy |
| 28312 | Osteotomy, shortening, angular or rotational correction; other phalanges, any toe | New Hampshire Precertification List, Pg 101 Original policy |
| 28315 | Sesamoidectomy, first toe (separate procedure) | New Hampshire Precertification List, Pg 101 Original policy |
| 28446 | Open osteochondral autograft, talus (includes obtaining grafts) | New Hampshire Precertification List, Pg 101 Original policy |
| 28750 | Arthrodesis, great toe; metatarsophalangeal joint | New Hampshire Precertification List, Pg 101 Original policy |
| 28890 | Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia | New Hampshire Precertification List, Pg 101 Original policy |
| 29800 | Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) | New Hampshire Precertification List, Pg 101 Original policy |
| 29804 | Arthroscopy, temporomandibular joint, surgical | New Hampshire Precertification List, Pg 101 Original policy |
| 29805 | Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) | New Hampshire Precertification List, Pg 101 Original policy |
| 29806 | Arthroscopy, shoulder, surgical; capsulorrhaphy | New Hampshire Precertification List, Pg 101 Original policy |
| 29807 | Arthroscopy, shoulder, surgical; repair of SLAP lesion | New Hampshire Precertification List, Pg 101 Original policy |
| 29819 | Arthroscopy, shoulder, surgical; with removal of loose body or foreign body | New Hampshire Precertification List, Pg 101 Original policy |
| 29820 | Arthroscopy, shoulder, surgical; synovectomy, partial | New Hampshire Precertification List, Pg 101 Original policy |
| 29821 | Arthroscopy, shoulder, surgical; synovectomy, complete | New Hampshire Precertification List, Pg 101 Original policy |
| 29822 | Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) | New Hampshire Precertification List, Pg 101 Original policy |
| 29823 | Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) | New Hampshire Precertification List, Pg 102 Original policy |
| 29824 | Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) | New Hampshire Precertification List, Pg 102 Original policy |
| 29825 | Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation | New Hampshire Precertification List, Pg 102 Original policy |
| 29826 | Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 102 Original policy |
| 29827 | Arthroscopy, shoulder, surgical; with rotator cuff repair | New Hampshire Precertification List, Pg 102 Original policy |
| 29828 | Arthroscopy, shoulder, surgical; biceps tenodesis | New Hampshire Precertification List, Pg 102 Original policy |