Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 3
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 |
|---|---|---|
| 95921 | Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio | New Hampshire Precertification List, Pg 12 Original policy |
| 95922 | Testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least 5 minutes of passive tilt | New Hampshire Precertification List, Pg 12 Original policy |
| 95923 | Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential | New Hampshire Precertification List, Pg 12 Original policy |
| 95924 | Testing of autonomic nervous system function; combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt | New Hampshire Precertification List, Pg 12 Original policy |
| 96934 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each additional lesion (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 13 Original policy |
| 96935 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, each additional lesion (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 13 Original policy |
| 96936 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, each additional lesion (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 13 Original policy |
| 99151 | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age | New Hampshire Precertification List, Pg 13 Original policy |
| 99152 | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older | New Hampshire Precertification List, Pg 13 Original policy |
| 99153 | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service) | New Hampshire Precertification List, Pg 13 Original policy |
| 99155 | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age | New Hampshire Precertification List, Pg 14 Original policy |
| 99156 | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older | New Hampshire Precertification List, Pg 14 Original policy |
| 99157 | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service) | New Hampshire Precertification List, Pg 14 Original policy |
| 0001U | Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported | New Hampshire Precertification List, Pg 14 Original policy |
| 0002M | Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A- 1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and alcoholic steatohepatitis (ASH) | New Hampshire Precertification List, Pg 14 Original policy |
| 0003M | Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A- 1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and nonalcoholic steatohepatitis (NASH) | New Hampshire Precertification List, Pg 14 Original policy |
| 0005U | Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score | New Hampshire Precertification List, Pg 14 Original policy |
| 0006M | Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk classifier | New Hampshire Precertification List, Pg 15 Original policy |
| 0007M | Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor disease index | New Hampshire Precertification List, Pg 15 Original policy |
| 0007U | Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, per date of service | New Hampshire Precertification List, Pg 15 Original policy |
| 0011M | Oncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and urine, algorithms to predict high-grade prostate cancer risk | New Hampshire Precertification List, Pg 15 Original policy |
| 0012M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma | New Hampshire Precertification List, Pg 15 Original policy |
| 0013M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having recurrent urothelial carcinoma | New Hampshire Precertification List, Pg 15 Original policy |
| 0016M | Oncology (bladder), mRNA, microarray gene expression profiling of 219 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine- like) | New Hampshire Precertification List, Pg 15 Original policy |
| 0016U | Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation | New Hampshire Precertification List, Pg 15 Original policy |
| 00170 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified | New Hampshire Precertification List, Pg 15 Original policy |
| 0017M | Oncology (diffuse large B-cell lymphoma [DLBCL]), mRNA, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffin-embedded tissue, algorithm reported as cell of origin | New Hampshire Precertification List, Pg 16 Original policy |
| 0017U | Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected | New Hampshire Precertification List, Pg 16 Original policy |
| 0018M | Transplantation medicine (allograft rejection, renal), measurement of donor and third-party-induced CD154+T- cytotoxic memory cells, utilizing whole peripheral blood, algorithm reported as a rejection risk score | New Hampshire Precertification List, Pg 16 Original policy |
| 0018U | Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy | New Hampshire Precertification List, Pg 16 Original policy |
| 0019U | Oncology, RNA, gene expression by whole transcriptome sequencing, formalin- fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents | New Hampshire Precertification List, Pg 16 Original policy |
| 0020M | Oncology (central nervous system), analys | New Hampshire Precertification List, Pg 16 Original policy |
| 0022U | Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence or absence of variants and associated therapy(ies) to consider | New Hampshire Precertification List, Pg 16 Original policy |
| 0023U | Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or non-detection of FLT3 mutation and indication for or against the use of midostaurin | New Hampshire Precertification List, Pg 16 Original policy |
| 0026U | Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ("Positive, high probability of malignancy" or "Negative, low probability of malignancy") | New Hampshire Precertification List, Pg 16 Original policy |
| 0027U | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 | New Hampshire Precertification List, Pg 17 Original policy |
| 0029U | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823) | New Hampshire Precertification List, Pg 17 Original policy |
| 0030U | Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823) | New Hampshire Precertification List, Pg 17 Original policy |
| 0031U | CYP1A2 (cytochrome P450 family 1, subfamily A, member 2)(eg, drug metabolism) gene analysis, common variants (ie, *1F, *1K, *6, *7) | New Hampshire Precertification List, Pg 17 Original policy |
| 0032U | COMT (catechol-O- methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant | New Hampshire Precertification List, Pg 17 Original policy |
| 0033U | HTR2A (5-hydroxytryptamine receptor 2A), HTR2C (5-hydroxytryptamine receptor 2C) (eg, citalopram metabolism) gene analysis, common variants (ie, HTR2A rs7997012 [c.614-2211T>C], HTR2C rs3813929 [c.-759C>T] and rs1414334 [c.551-3008C>G]) | New Hampshire Precertification List, Pg 17 Original policy |
| 0034U | TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15)(eg, thiopurine metabolism) gene analysis, common variants (ie, TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *12; NUDT15 *3, *4, *5) | New Hampshire Precertification List, Pg 17 Original policy |
| 0036U | Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses | New Hampshire Precertification List, Pg 17 Original policy |
| 0037U | Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden | New Hampshire Precertification List, Pg 17 Original policy |
| 0040U | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative | New Hampshire Precertification List, Pg 17 Original policy |
| 0042T | Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time | New Hampshire Precertification List, Pg 18 Original policy |
| 0045U | Oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin- fixed paraffin-embedded tissue, algorithm reported as recurrence score | New Hampshire Precertification List, Pg 18 Original policy |
| 0046U | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative | New Hampshire Precertification List, Pg 18 Original policy |
| 0047U | Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a risk score | New Hampshire Precertification List, Pg 18 Original policy |
| 0048U | Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatellite instability, matched with normal specimens, utilizing formalin-fixed paraffin-embedded tumor tissue, report of clinically significant mutation(s) | New Hampshire Precertification List, Pg 18 Original policy |