Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 23
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 |
|---|---|---|
| 29860 | Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) | New Hampshire Precertification List, Pg 102 Original policy |
| 29861 | Arthroscopy, hip, surgical; with removal of loose body or foreign body | New Hampshire Precertification List, Pg 102 Original policy |
| 29862 | Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum | New Hampshire Precertification List, Pg 102 Original policy |
| 29863 | Arthroscopy, hip, surgical; with synovectomy | New Hampshire Precertification List, Pg 102 Original policy |
| 29866 | Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) | New Hampshire Precertification List, Pg 102 Original policy |
| 29867 | Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty) | New Hampshire Precertification List, Pg 102 Original policy |
| 29868 | Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral | New Hampshire Precertification List, Pg 102 Original policy |
| 29870 | Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) | New Hampshire Precertification List, Pg 102 Original policy |
| 29871 | Arthroscopy, knee, surgical; for infection, lavage and drainage | New Hampshire Precertification List, Pg 102 Original policy |
| 29873 | Arthroscopy, knee, surgical; with lateral release | New Hampshire Precertification List, Pg 102 Original policy |
| 29874 | Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) | New Hampshire Precertification List, Pg 103 Original policy |
| 29875 | Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure) | New Hampshire Precertification List, Pg 103 Original policy |
| 29876 | Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) | New Hampshire Precertification List, Pg 103 Original policy |
| 29877 | Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) | New Hampshire Precertification List, Pg 103 Original policy |
| 29879 | Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture | New Hampshire Precertification List, Pg 103 Original policy |
| 29880 | Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed | New Hampshire Precertification List, Pg 103 Original policy |
| 29881 | Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed | New Hampshire Precertification List, Pg 103 Original policy |
| 29882 | Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) | New Hampshire Precertification List, Pg 103 Original policy |
| 29883 | Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) | New Hampshire Precertification List, Pg 103 Original policy |
| 29884 | Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure) | New Hampshire Precertification List, Pg 103 Original policy |
| 29885 | Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) | New Hampshire Precertification List, Pg 103 Original policy |
| 29886 | Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion | New Hampshire Precertification List, Pg 103 Original policy |
| 29887 | Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation | New Hampshire Precertification List, Pg 103 Original policy |
| 29888 | Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction | New Hampshire Precertification List, Pg 103 Original policy |
| 29889 | Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction | New Hampshire Precertification List, Pg 103 Original policy |
| 29892 | Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy) | New Hampshire Precertification List, Pg 104 Original policy |
| 29914 | Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) | New Hampshire Precertification List, Pg 104 Original policy |
| 29915 | Arthroscopy, subtalar joint, surgical; with acetabuloplasty (ie, treatment of pincer lesion) | New Hampshire Precertification List, Pg 104 Original policy |
| 29916 | Arthroscopy, hip, surgical; with labral repair | New Hampshire Precertification List, Pg 104 Original policy |
| 30120 | Excision or surgical planing of skin of nose for rhinophyma | New Hampshire Precertification List, Pg 104 Original policy |
| 30400 | Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip | New Hampshire Precertification List, Pg 104 Original policy |
| 30410 | Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip | New Hampshire Precertification List, Pg 104 Original policy |
| 30420 | Rhinoplasty, primary; including major septal repair | New Hampshire Precertification List, Pg 104 Original policy |
| 30430 | Rhinoplasty, secondary; minor revision (small amount of nasal tip work) | New Hampshire Precertification List, Pg 104 Original policy |
| 30435 | Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) | New Hampshire Precertification List, Pg 104 Original policy |
| 30450 | Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) | New Hampshire Precertification List, Pg 104 Original policy |
| 30468 | Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s) | New Hampshire Precertification List, Pg 104 Original policy |
| 30469 | Repair of nasal valve collapse with low energy, temperature-controlled (ie, radiofrequency) subcutaneous/submucosal remodeling | New Hampshire Precertification List, Pg 104 Original policy |
| 31242 | Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation, posterior nasal nerve | New Hampshire Precertification List, Pg 104 Original policy |
| 31243 | Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve | New Hampshire Precertification List, Pg 104 Original policy |
| 31574 | Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), unilateral | New Hampshire Precertification List, Pg 104 Original policy |
| 31643 | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of catheter(s) for intracavitary radioelement application | New Hampshire Precertification List, Pg 104 Original policy |
| 31660 | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe | New Hampshire Precertification List, Pg 104 Original policy |
| 31661 | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes | New Hampshire Precertification List, Pg 105 Original policy |
| 32701 | Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment | New Hampshire Precertification List, Pg 105 Original policy |
| 32850 | Donor pneumonectomy(s) (including cold preservation), from cadaver donor | New Hampshire Precertification List, Pg 105 Original policy |
| 32851 | Lung transplant, single; without cardiopulmonary bypass | New Hampshire Precertification List, Pg 105 Original policy |
| 32852 | Lung transplant, single; with cardiopulmonary bypass | New Hampshire Precertification List, Pg 105 Original policy |
| 32853 | Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass | New Hampshire Precertification List, Pg 105 Original policy |
| 32854 | Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass | New Hampshire Precertification List, Pg 105 Original policy |