Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 25
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 |
|---|---|---|
| 33340 | Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation | New Hampshire Precertification List, Pg 109 Original policy |
| 33361 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach | New Hampshire Precertification List, Pg 109 Original policy |
| 33362 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach | New Hampshire Precertification List, Pg 109 Original policy |
| 33363 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach | New Hampshire Precertification List, Pg 109 Original policy |
| 33364 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach | New Hampshire Precertification List, Pg 109 Original policy |
| 33365 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy) | New Hampshire Precertification List, Pg 109 Original policy |
| 33366 | Transcatheter aortic valve replacement (tavr/tavi) with prosthetic valve; transapical exposure (eg, left thoracotomy) | New Hampshire Precertification List, Pg 110 Original policy |
| 33418 | Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis | New Hampshire Precertification List, Pg 110 Original policy |
| 33477 | Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed | New Hampshire Precertification List, Pg 110 Original policy |
| 33548 | Surgical ventricular restoration procedure, includes prosthetic patch, when performed (eg, ventricular remodeling, SVR, SAVER, Dor procedures) | New Hampshire Precertification List, Pg 110 Original policy |
| 33927 | Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy | New Hampshire Precertification List, Pg 110 Original policy |
| 33928 | Removal and replacement of total replacement heart system (artificial heart) | New Hampshire Precertification List, Pg 110 Original policy |
| 33930 | Donor cardiectomy-pneumonectomy (including cold preservation) | New Hampshire Precertification List, Pg 110 Original policy |
| 33933 | Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation | New Hampshire Precertification List, Pg 110 Original policy |
| 33935 | Heart-lung transplant with recipient cardiectomy-pneumonectomy | New Hampshire Precertification List, Pg 110 Original policy |
| 33940 | Donor cardiectomy (including cold preservation) | New Hampshire Precertification List, Pg 110 Original policy |
| 33944 | Backbench standard preparation of cadaver donor heart allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, pulmonary artery, and left atrium for implantation | New Hampshire Precertification List, Pg 110 Original policy |
| 33945 | Heart transplant, with or without recipient cardiectomy | New Hampshire Precertification List, Pg 110 Original policy |
| 33975 | Insertion of ventricular assist device; extracorporeal, single ventricle | New Hampshire Precertification List, Pg 110 Original policy |
| 33976 | Insertion of ventricular assist device; extracorporeal, biventricular | New Hampshire Precertification List, Pg 110 Original policy |
| 33979 | Insertion of ventricular assist device, implantable intracorporeal, single ventricle | New Hampshire Precertification List, Pg 110 Original policy |
| 33981 | Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump | New Hampshire Precertification List, Pg 110 Original policy |
| 33982 | Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass | New Hampshire Precertification List, Pg 111 Original policy |
| 33983 | Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass | New Hampshire Precertification List, Pg 111 Original policy |
| 33990 | Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, arterial access only | New Hampshire Precertification List, Pg 111 Original policy |
| 33991 | Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, both arterial and venous access, with transseptal puncture | New Hampshire Precertification List, Pg 111 Original policy |
| 33993 | Repositioning of percutaneous right or left heart ventricular assist device with imaging guidance at separate and distinct session from insertion | New Hampshire Precertification List, Pg 111 Original policy |
| 33995 | Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right heart, venous access only | New Hampshire Precertification List, Pg 111 Original policy |
| 36465 | Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein) | New Hampshire Precertification List, Pg 111 Original policy |
| 36466 | Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg | New Hampshire Precertification List, Pg 111 Original policy |
| 36468 | Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk | New Hampshire Precertification List, Pg 111 Original policy |
| 36470 | Injection of sclerosant; single incompetent vein (other than telangiectasia) | New Hampshire Precertification List, Pg 111 Original policy |
| 36471 | Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg | New Hampshire Precertification List, Pg 111 Original policy |
| 36473 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated | New Hampshire Precertification List, Pg 111 Original policy |
| 36475 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated | New Hampshire Precertification List, Pg 112 Original policy |
| 36478 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated | New Hampshire Precertification List, Pg 112 Original policy |
| 36482 | Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated | New Hampshire Precertification List, Pg 112 Original policy |
| 36511 | Therapeutic apheresis; for white blood cells | New Hampshire Precertification List, Pg 112 Original policy |
| 36512 | Therapeutic apheresis; for red blood cells | New Hampshire Precertification List, Pg 112 Original policy |
| 36513 | Therapeutic apheresis; for platelets | New Hampshire Precertification List, Pg 112 Original policy |
| 36514 | Therapeutic apheresis; for plasma pheresis | New Hampshire Precertification List, Pg 112 Original policy |
| 36516 | Therapeutic apheresis; with extracorporeal immunoadsorption, selective adsorption or selective filtration and plasma reinfusion | New Hampshire Precertification List, Pg 112 Original policy |
| 37220 | Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty | New Hampshire Precertification List, Pg 112 Original policy |
| 37221 | Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed | New Hampshire Precertification List, Pg 112 Original policy |
| 37222 | Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 112 Original policy |
| 37223 | Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 112 Original policy |
| 37224 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty | New Hampshire Precertification List, Pg 112 Original policy |
| 37225 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed | New Hampshire Precertification List, Pg 113 Original policy |
| 37226 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed | New Hampshire Precertification List, Pg 113 Original policy |
| 37227 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed | New Hampshire Precertification List, Pg 113 Original policy |