Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 28
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 |
|---|---|---|
| 47146 | Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each | New Hampshire Precertification List, Pg 121 Original policy |
| 47147 | Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each | New Hampshire Precertification List, Pg 121 Original policy |
| 48160 | Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells | New Hampshire Precertification List, Pg 121 Original policy |
| 48550 | Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation | New Hampshire Precertification List, Pg 121 Original policy |
| 48551 | Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy, ligation of bile duct, ligation of mesenteric vessels, and Y-graft arterial anastomoses from iliac artery to superior mesenteric artery and to splenic artery | New Hampshire Precertification List, Pg 121 Original policy |
| 48552 | Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, each | New Hampshire Precertification List, Pg 121 Original policy |
| 48554 | Transplantation of pancreatic allograft | New Hampshire Precertification List, Pg 121 Original policy |
| 48556 | Removal of transplanted pancreatic allograft | New Hampshire Precertification List, Pg 121 Original policy |
| 49906 | Free omental flap with microvascular anastomosis | New Hampshire Precertification List, Pg 121 Original policy |
| 50250 | Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed | New Hampshire Precertification List, Pg 121 Original policy |
| 50300 | Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral | New Hampshire Precertification List, Pg 121 Original policy |
| 50320 | Donor nephrectomy (including cold preservation); open, from living donor | New Hampshire Precertification List, Pg 121 Original policy |
| 50323 | Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary | New Hampshire Precertification List, Pg 121 Original policy |
| 50325 | Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary | New Hampshire Precertification List, Pg 122 Original policy |
| 50327 | Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each | New Hampshire Precertification List, Pg 122 Original policy |
| 50328 | Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each | New Hampshire Precertification List, Pg 122 Original policy |
| 50329 | Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, each | New Hampshire Precertification List, Pg 122 Original policy |
| 50340 | Recipient nephrectomy (separate procedure) | New Hampshire Precertification List, Pg 122 Original policy |
| 50360 | Renal allotransplantation, implantation of graft; without recipient nephrectomy | New Hampshire Precertification List, Pg 122 Original policy |
| 50365 | Renal allotransplantation, implantation of graft; with recipient nephrectomy | New Hampshire Precertification List, Pg 122 Original policy |
| 50370 | Removal of transplanted renal allograft | New Hampshire Precertification List, Pg 122 Original policy |
| 50542 | Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when performed | New Hampshire Precertification List, Pg 122 Original policy |
| 50547 | Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor | New Hampshire Precertification List, Pg 122 Original policy |
| 50592 | Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency | New Hampshire Precertification List, Pg 122 Original policy |
| 50593 | Ablation, renal tumor(s), unilateral, presutaneous cryotherapy | New Hampshire Precertification List, Pg 122 Original policy |
| 51715 | Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck | New Hampshire Precertification List, Pg 122 Original policy |
| 53445 | Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff | New Hampshire Precertification List, Pg 122 Original policy |
| 53446 | Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff | New Hampshire Precertification List, Pg 122 Original policy |
| 53447 | Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session | New Hampshire Precertification List, Pg 122 Original policy |
| 53448 | Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session including irrigation and debridement of infected tissue | New Hampshire Precertification List, Pg 123 Original policy |
| 53449 | Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff | New Hampshire Precertification List, Pg 123 Original policy |
| 53451 | Periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance | New Hampshire Precertification List, Pg 123 Original policy |
| 53452 | Periurethral transperineal adjustable balloon continence device; unilateral insertion, including cystourethroscopy and imaging guidance | New Hampshire Precertification List, Pg 123 Original policy |
| 53453 | Periurethral transperineal adjustable balloon continence device; removal, each balloon | New Hampshire Precertification List, Pg 123 Original policy |
| 53454 | Periurethral transperineal adjustable balloon continence device; percutaneous adjustment of balloon(s) fluid volume | New Hampshire Precertification List, Pg 123 Original policy |
| 53850 | Transurethral destruction of prostate tissue; by microwave thermotherapy | New Hampshire Precertification List, Pg 123 Original policy |
| 53852 | Transurethral destruction of prostate tissue; by radiofrequency thermotherapy | New Hampshire Precertification List, Pg 123 Original policy |
| 53860 | Transurethral radiofrequency micro- remodeling of the female bladder neck and proximal urethra for stress urinary incontinence | New Hampshire Precertification List, Pg 123 Original policy |
| 54125 | Amputation of penis; complete | New Hampshire Precertification List, Pg 123 Original policy |
| 54360 | Plastic operation on penis to correct angulation | New Hampshire Precertification List, Pg 123 Original policy |
| 54400 | Insertion of penile prosthesis; non- inflatable (semi-rigid) | New Hampshire Precertification List, Pg 123 Original policy |
| 54401 | Insertion of penile prosthesis; inflatable (self-contained) | New Hampshire Precertification List, Pg 123 Original policy |
| 54405 | Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir | New Hampshire Precertification List, Pg 123 Original policy |
| 54440 | Plastic operation of penis for injury | New Hampshire Precertification List, Pg 123 Original policy |
| 54520 | Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach | New Hampshire Precertification List, Pg 123 Original policy |
| 54660 | Insertion of testicular prosthesis (separate procedure) | New Hampshire Precertification List, Pg 123 Original policy |
| 54690 | Laparoscopy, surgical; orchiectomy | New Hampshire Precertification List, Pg 123 Original policy |
| 55180 | Scrotoplasty; complicated | New Hampshire Precertification List, Pg 123 Original policy |
| 55706 | Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance | New Hampshire Precertification List, Pg 123 Original policy |
| 55860 | Exposure of prostate, any approach, for insertion of radioactive substance | New Hampshire Precertification List, Pg 124 Original policy |