Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 27
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 |
|---|---|---|
| 43254 | Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection | New Hampshire Precertification List, Pg 117 Original policy |
| 43255 | Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method | New Hampshire Precertification List, Pg 117 Original policy |
| 43257 | Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease | New Hampshire Precertification List, Pg 117 Original policy |
| 43266 | Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) | New Hampshire Precertification List, Pg 117 Original policy |
| 43270 | Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) | New Hampshire Precertification List, Pg 117 Original policy |
| 43281 | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh | New Hampshire Precertification List, Pg 117 Original policy |
| 43282 | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh | New Hampshire Precertification List, Pg 117 Original policy |
| 43284 | Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed | New Hampshire Precertification List, Pg 117 Original policy |
| 43285 | Removal of esophageal sphincter augmentation device | New Hampshire Precertification List, Pg 117 Original policy |
| 43290 | Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon | New Hampshire Precertification List, Pg 118 Original policy |
| 43291 | Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s) | New Hampshire Precertification List, Pg 118 Original policy |
| 43497 | Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM]) | New Hampshire Precertification List, Pg 118 Original policy |
| 43632 | Gastrectomy, partial, distal; with gastrojejunostomy | New Hampshire Precertification List, Pg 118 Original policy |
| 43633 | Gastrectomy, partial, distal; with Roux-en- Y reconstruction | New Hampshire Precertification List, Pg 118 Original policy |
| 43644 | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux- en-Y gastroenterostomy (roux limb 150 cm or less) | New Hampshire Precertification List, Pg 118 Original policy |
| 43645 | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption | New Hampshire Precertification List, Pg 118 Original policy |
| 43770 | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) | New Hampshire Precertification List, Pg 118 Original policy |
| 43771 | Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only | New Hampshire Precertification List, Pg 118 Original policy |
| 43772 | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only | New Hampshire Precertification List, Pg 118 Original policy |
| 43773 | Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only | New Hampshire Precertification List, Pg 118 Original policy |
| 43774 | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components | New Hampshire Precertification List, Pg 118 Original policy |
| 43775 | Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) | New Hampshire Precertification List, Pg 118 Original policy |
| 43842 | Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty | New Hampshire Precertification List, Pg 118 Original policy |
| 43843 | Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty | New Hampshire Precertification List, Pg 118 Original policy |
| 43845 | Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) | New Hampshire Precertification List, Pg 119 Original policy |
| 43846 | Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy | New Hampshire Precertification List, Pg 119 Original policy |
| 43847 | Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption | New Hampshire Precertification List, Pg 119 Original policy |
| 43848 | Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) | New Hampshire Precertification List, Pg 119 Original policy |
| 43886 | Gastric restrictive procedure, open; revision of subcutaneous port component only | New Hampshire Precertification List, Pg 119 Original policy |
| 43887 | Gastric restrictive procedure, open; removal of subcutaneous port component only | New Hampshire Precertification List, Pg 119 Original policy |
| 43888 | Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only | New Hampshire Precertification List, Pg 119 Original policy |
| 43999 | Unlisted procedure, stomach | New Hampshire Precertification List, Pg 119 Original policy |
| 44132 | Donor enterectomy (including cold preservation), open; from cadaver donor | New Hampshire Precertification List, Pg 119 Original policy |
| 44133 | Donor enterectomy (including cold preservation), open; partial, from living donor | New Hampshire Precertification List, Pg 119 Original policy |
| 44135 | Intestinal allotransplantation; from cadaver donor | New Hampshire Precertification List, Pg 119 Original policy |
| 44136 | Intestinal allotransplantation; from living donor | New Hampshire Precertification List, Pg 119 Original policy |
| 44715 | Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein | New Hampshire Precertification List, Pg 119 Original policy |
| 44720 | Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each | New Hampshire Precertification List, Pg 119 Original policy |
| 44721 | Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each | New Hampshire Precertification List, Pg 119 Original policy |
| 46607 | Anoscopy; with high-resolution magnificati | New Hampshire Precertification List, Pg 119 Original policy |
| 46707 | Repair of anorectal fistula with plug (eg, porcine small intestine submucosa [SIS]) | New Hampshire Precertification List, Pg 119 Original policy |
| 46948 | Hemorrhoidectomy, internal, by transanal hemorrhoidal dearterialization, 2 or more hemorrhoid columns/groups, including ultrasound guidance, with mucopexy, when performed | New Hampshire Precertification List, Pg 120 Original policy |
| 47133 | Donor hepatectomy (including cold preservation), from cadaver donor | New Hampshire Precertification List, Pg 120 Original policy |
| 47135 | Liver allotransplantation, orthotopic, partial or whole, from cadaver or living donor, any age | New Hampshire Precertification List, Pg 120 Original policy |
| 47140 | Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III) | New Hampshire Precertification List, Pg 120 Original policy |
| 47141 | Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III and IV) | New Hampshire Precertification List, Pg 120 Original policy |
| 47142 | Donor hepatectomy (including cold preservation), from living donor; total right lobectomy (segments V, VI, VII and VIII) | New Hampshire Precertification List, Pg 120 Original policy |
| 47143 | Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe split | New Hampshire Precertification List, Pg 120 Original policy |
| 47144 | Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with trisegment split of whole liver graft into 2 partial liver grafts (ie, left lateral segment [segments II and III] and right trisegment [segments I and IV through VIII]) | New Hampshire Precertification List, Pg 120 Original policy |
| 47145 | Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with lobe split of whole liver graft into 2 partial liver grafts (ie, left lobe [segments II, III, and IV] and right lobe [segments I and V through VIII]) | New Hampshire Precertification List, Pg 120 Original policy |