Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 32
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 |
|---|---|---|
| 64520 | Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) | New Hampshire Precertification List, Pg 137 Original policy |
| 64553 | Percutaneous implantation of neurostimulator electrode array; cranial nerve | New Hampshire Precertification List, Pg 137 Original policy |
| 64555 | Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) | New Hampshire Precertification List, Pg 137 Original policy |
| 64561 | Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed | New Hampshire Precertification List, Pg 137 Original policy |
| 64566 | Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming | New Hampshire Precertification List, Pg 137 Original policy |
| 64568 | Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator | New Hampshire Precertification List, Pg 137 Original policy |
| 64569 | Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator | New Hampshire Precertification List, Pg 137 Original policy |
| 64575 | Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) | New Hampshire Precertification List, Pg 137 Original policy |
| 64581 | Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) | New Hampshire Precertification List, Pg 137 Original policy |
| 64582 | Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array | New Hampshire Precertification List, Pg 137 Original policy |
| 64585 | Revision or removal of peripheral neurostimulator electrode array | New Hampshire Precertification List, Pg 137 Original policy |
| 64590 | Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver | New Hampshire Precertification List, Pg 137 Original policy |
| 64596 | Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode array | New Hampshire Precertification List, Pg 137 Original policy |
| 64600 | Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch | New Hampshire Precertification List, Pg 137 Original policy |
| 64605 | Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale | New Hampshire Precertification List, Pg 137 Original policy |
| 64610 | Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring | New Hampshire Precertification List, Pg 138 Original policy |
| 64624 | Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed | New Hampshire Precertification List, Pg 138 Original policy |
| 64625 | Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) | New Hampshire Precertification List, Pg 138 Original policy |
| 64628 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral | New Hampshire Precertification List, Pg 138 Original policy |
| 64629 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 138 Original policy |
| 64633 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint | New Hampshire Precertification List, Pg 138 Original policy |
| 64634 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 138 Original policy |
| 64635 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint | New Hampshire Precertification List, Pg 138 Original policy |
| 64636 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 138 Original policy |
| 64640 | Destruction by neurolytic agent; other peripheral nerve or branch | New Hampshire Precertification List, Pg 138 Original policy |
| 64642 | Chemodenervation of one extremity; 1-4 muscle(s) | New Hampshire Precertification List, Pg 138 Original policy |
| 64644 | Chemodenervation of one extremity; 5 or more muscle(s) | New Hampshire Precertification List, Pg 138 Original policy |
| 64646 | Chemodenervation of trunk muscle(s); 1- 5 muscle(s) | New Hampshire Precertification List, Pg 138 Original policy |
| 64647 | Chemodenervation of trunk muscle(s); 6 or more muscle(s) | New Hampshire Precertification List, Pg 138 Original policy |
| 64650 | Chemodenervation of eccrine glands; both axillae | New Hampshire Precertification List, Pg 138 Original policy |
| 64653 | Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day | New Hampshire Precertification List, Pg 138 Original policy |
| 64716 | Neuroplasty and/or transposition; cranial nerve (specify) | New Hampshire Precertification List, Pg 139 Original policy |
| 64722 | Decompression; unspecified nerve(s) (specify) | New Hampshire Precertification List, Pg 139 Original policy |
| 64732 | Transection or avulsion of; supraorbital nerve | New Hampshire Precertification List, Pg 139 Original policy |
| 64734 | Transection or avulsion of; infraorbital nerve | New Hampshire Precertification List, Pg 139 Original policy |
| 64736 | Transection or avulsion of; mental nerve | New Hampshire Precertification List, Pg 139 Original policy |
| 64738 | Transection or avulsion of; inferior alveolar nerve by osteotomy | New Hampshire Precertification List, Pg 139 Original policy |
| 64740 | Transection or avulsion of; lingual nerve | New Hampshire Precertification List, Pg 139 Original policy |
| 64742 | Transection or avulsion of; facial nerve, differential or complete | New Hampshire Precertification List, Pg 139 Original policy |
| 64744 | Transection or avulsion of; greater occipital nerve | New Hampshire Precertification List, Pg 139 Original policy |
| 64771 | Transection or avulsion of other cranial nerve, extradural | New Hampshire Precertification List, Pg 139 Original policy |
| 64772 | Transection or avulsion of other spinal nerve, extradural | New Hampshire Precertification List, Pg 139 Original policy |
| 64864 | Suture of facial nerve; extracranial | New Hampshire Precertification List, Pg 139 Original policy |
| 64865 | Suture of facial nerve; infratemporal, with or without grafting | New Hampshire Precertification List, Pg 139 Original policy |
| 64866 | Anastomosis; facial-spinal accessory | New Hampshire Precertification List, Pg 139 Original policy |
| 64868 | Anastomosis; facial-hypoglossal | New Hampshire Precertification List, Pg 139 Original policy |
| 65778 | Placement of amniotic membrane on the ocular surface; without sutures | New Hampshire Precertification List, Pg 139 Original policy |
| 65779 | Placement of amniotic membrane on the ocular surface; single layer, sutured | New Hampshire Precertification List, Pg 139 Original policy |
| 65780 | Ocular surface reconstruction; amniotic membrane transplantation, multiple layers | New Hampshire Precertification List, Pg 139 Original policy |
| 66174 | Transluminal dilation of aqueous outflow canal (eg, canaloplasty); without retention of device or stent | New Hampshire Precertification List, Pg 139 Original policy |