Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 29
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 |
|---|---|---|
| 55862 | Exposure of prostate, any approach, for insertion of radioactive substance; with lymph node biopsy(s) (limited pelvic lymphadenectomy) | New Hampshire Precertification List, Pg 124 Original policy |
| 55865 | Exposure of prostate, any approach, for insertion of radioactive substance; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes | New Hampshire Precertification List, Pg 124 Original policy |
| 55873 | Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) | New Hampshire Precertification List, Pg 124 Original policy |
| 55874 | Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed | New Hampshire Precertification List, Pg 124 Original policy |
| 55875 | Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy | New Hampshire Precertification List, Pg 124 Original policy |
| 55920 | Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application | New Hampshire Precertification List, Pg 124 Original policy |
| 56625 | Vulvectomy simple; complete | New Hampshire Precertification List, Pg 124 Original policy |
| 56800 | Plastic repair of introitus | New Hampshire Precertification List, Pg 124 Original policy |
| 56805 | Clitoroplasty for intersex state | New Hampshire Precertification List, Pg 124 Original policy |
| 56810 | Perineoplasty, repair of perineum, nonobstetrical (separate procedure) | New Hampshire Precertification List, Pg 124 Original policy |
| 57110 | Vaginectomy, complete removal of vaginal wall | New Hampshire Precertification List, Pg 124 Original policy |
| 57155 | Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy | New Hampshire Precertification List, Pg 124 Original policy |
| 57156 | Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy | New Hampshire Precertification List, Pg 124 Original policy |
| 57265 | Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed; with enterocele repair | New Hampshire Precertification List, Pg 124 Original policy |
| 57270 | Repair of enterocele, abdominal approach (separate procedure) | New Hampshire Precertification List, Pg 124 Original policy |
| 57280 | Colpopexy, abdominal approach | New Hampshire Precertification List, Pg 124 Original policy |
| 57283 | Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy) | New Hampshire Precertification List, Pg 124 Original policy |
| 57284 | Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach | New Hampshire Precertification List, Pg 124 Original policy |
| 57285 | Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach | New Hampshire Precertification List, Pg 124 Original policy |
| 57291 | Construction of artificial vagina; without graft | New Hampshire Precertification List, Pg 125 Original policy |
| 57292 | Construction of artificial vagina; with graft | New Hampshire Precertification List, Pg 125 Original policy |
| 57295 | Revision (including removal) of prosthetic vaginal graft, vaginal approach | New Hampshire Precertification List, Pg 125 Original policy |
| 57296 | Revision (including removal) of prosthetic vaginal graft; open abdominal approach | New Hampshire Precertification List, Pg 125 Original policy |
| 57335 | Vaginoplasty for intersex state | New Hampshire Precertification List, Pg 125 Original policy |
| 57423 | Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach | New Hampshire Precertification List, Pg 125 Original policy |
| 58150 | Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) | New Hampshire Precertification List, Pg 125 Original policy |
| 58346 | Insertion of Heyman capsules for clinical brachytherapy | New Hampshire Precertification List, Pg 125 Original policy |
| 58552 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) | New Hampshire Precertification List, Pg 125 Original policy |
| 58554 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) | New Hampshire Precertification List, Pg 125 Original policy |
| 58570 | Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less | New Hampshire Precertification List, Pg 125 Original policy |
| 58571 | Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less;with removal of tube(s) and/or ovary (s) | New Hampshire Precertification List, Pg 125 Original policy |
| 58572 | Laparoscopy; surgical, with total hysterectomy, for uterus greater than 250 g | New Hampshire Precertification List, Pg 125 Original policy |
| 58573 | Laparoscopy; surgical, with total hysterectomy, for uterus greater than 250 g, with removal of tube(s) and/or ovary (s) | New Hampshire Precertification List, Pg 125 Original policy |
| 58580 | Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency | New Hampshire Precertification List, Pg 125 Original policy |
| 58674 | Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency | New Hampshire Precertification List, Pg 125 Original policy |
| 60660 | Percutaneous ablation of 1 or more thyroi | New Hampshire Precertification List, Pg 125 Original policy |
| 61715 | Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation of target, intracranial, including stereotactic navigation and frame placement, when performed | New Hampshire Precertification List, Pg 125 Original policy |
| 61736 | Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 simple lesion | New Hampshire Precertification List, Pg 126 Original policy |
| 61737 | Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; multiple trajectories for multiple or complex lesion(s) | New Hampshire Precertification List, Pg 126 Original policy |
| 61790 | Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); gasserian ganglion | New Hampshire Precertification List, Pg 126 Original policy |
| 61791 | Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); trigeminal medullary tract | New Hampshire Precertification List, Pg 126 Original policy |
| 61796 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion | New Hampshire Precertification List, Pg 126 Original policy |
| 61798 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion | New Hampshire Precertification List, Pg 126 Original policy |
| 61850 | Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical | New Hampshire Precertification List, Pg 126 Original policy |
| 61860 | Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical | New Hampshire Precertification List, Pg 126 Original policy |
| 61863 | Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array | New Hampshire Precertification List, Pg 126 Original policy |
| 61867 | Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array | New Hampshire Precertification List, Pg 126 Original policy |
| 61885 | Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array | New Hampshire Precertification List, Pg 126 Original policy |
| 61886 | Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays | New Hampshire Precertification List, Pg 127 Original policy |
| 61889 | Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, when performed, with direct or inductive coupling, with connection to depth and/or cortical strip electrode array(s) | New Hampshire Precertification List, Pg 127 Original policy |