Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 31
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 |
|---|---|---|
| 63190 | Laminectomy with rhizotomy; more than 2 segments | New Hampshire Precertification List, Pg 133 Original policy |
| 63191 | Laminectomy with section of spinal accessory nerve | New Hampshire Precertification List, Pg 133 Original policy |
| 63200 | Laminectomy, with release of tethered spinal cord, lumbar | New Hampshire Precertification List, Pg 133 Original policy |
| 63250 | Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical | New Hampshire Precertification List, Pg 133 Original policy |
| 63252 | Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar | New Hampshire Precertification List, Pg 133 Original policy |
| 63265 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical | New Hampshire Precertification List, Pg 133 Original policy |
| 63267 | Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar | New Hampshire Precertification List, Pg 133 Original policy |
| 63270 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical | New Hampshire Precertification List, Pg 133 Original policy |
| 63272 | Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar | New Hampshire Precertification List, Pg 133 Original policy |
| 63275 | Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical | New Hampshire Precertification List, Pg 133 Original policy |
| 63277 | Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar | New Hampshire Precertification List, Pg 133 Original policy |
| 63280 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical | New Hampshire Precertification List, Pg 133 Original policy |
| 63282 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar | New Hampshire Precertification List, Pg 133 Original policy |
| 63285 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical | New Hampshire Precertification List, Pg 134 Original policy |
| 63287 | Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar | New Hampshire Precertification List, Pg 134 Original policy |
| 63290 | Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level | New Hampshire Precertification List, Pg 134 Original policy |
| 63300 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical | New Hampshire Precertification List, Pg 134 Original policy |
| 63301 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by transthoracic approach | New Hampshire Precertification List, Pg 134 Original policy |
| 63302 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by thoracolumbar approach | New Hampshire Precertification List, Pg 134 Original policy |
| 63303 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal approach | New Hampshire Precertification List, Pg 134 Original policy |
| 63304 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, cervical | New Hampshire Precertification List, Pg 134 Original policy |
| 63305 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by transthoracic approach | New Hampshire Precertification List, Pg 134 Original policy |
| 63306 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by thoracolumbar approach | New Hampshire Precertification List, Pg 134 Original policy |
| 63307 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach | New Hampshire Precertification List, Pg 134 Original policy |
| 63308 | Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; each additional segment (List separately in addition to codes for single segment) | New Hampshire Precertification List, Pg 134 Original policy |
| 63620 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion | New Hampshire Precertification List, Pg 135 Original policy |
| 63650 | Percutaneous implantation of neurostimulator electrode array, epidural | New Hampshire Precertification List, Pg 135 Original policy |
| 63655 | Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural | New Hampshire Precertification List, Pg 135 Original policy |
| 63663 | Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed | New Hampshire Precertification List, Pg 135 Original policy |
| 63664 | Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed | New Hampshire Precertification List, Pg 135 Original policy |
| 63685 | Insertion or replacement of spinal neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver | New Hampshire Precertification List, Pg 135 Original policy |
| 63688 | Revision or removal of implanted spinal neurostimulator pulse generator or receiver, with detachable connection to electrode array | New Hampshire Precertification List, Pg 135 Original policy |
| 64405 | Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve | New Hampshire Precertification List, Pg 135 Original policy |
| 64415 | Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed | New Hampshire Precertification List, Pg 135 Original policy |
| 64417 | Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance, when performed | New Hampshire Precertification List, Pg 135 Original policy |
| 64447 | Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance, when performed | New Hampshire Precertification List, Pg 135 Original policy |
| 64450 | Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch | New Hampshire Precertification List, Pg 135 Original policy |
| 64454 | Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed | New Hampshire Precertification List, Pg 135 Original policy |
| 64479 | Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level | New Hampshire Precertification List, Pg 135 Original policy |
| 64480 | Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 135 Original policy |
| 64483 | Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level | New Hampshire Precertification List, Pg 136 Original policy |
| 64484 | Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 136 Original policy |
| 64490 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level | New Hampshire Precertification List, Pg 136 Original policy |
| 64491 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 136 Original policy |
| 64492 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 136 Original policy |
| 64493 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level | New Hampshire Precertification List, Pg 136 Original policy |
| 64494 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 136 Original policy |
| 64495 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 136 Original policy |
| 64505 | Injection, anesthetic agent; sphenopalatine ganglion | New Hampshire Precertification List, Pg 136 Original policy |
| 64510 | Injection, anesthetic agent; stellate ganglion (cervical sympathetic) | New Hampshire Precertification List, Pg 137 Original policy |