Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 33
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 |
|---|---|---|
| 66175 | Transluminal dilation of aqueous outflow canal (eg, canaloplasty); with retention of device or stent | New Hampshire Precertification List, Pg 139 Original policy |
| 66183 | Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach | New Hampshire Precertification List, Pg 139 Original policy |
| 66683 | Implantation of iris prosthesis, including suture fixation and repair or removal of iris, when performed | New Hampshire Precertification List, Pg 139 Original policy |
| 66989 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1- stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more | New Hampshire Precertification List, Pg 140 Original policy |
| 66991 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more | New Hampshire Precertification List, Pg 140 Original policy |
| 67027 | Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of vitreous | New Hampshire Precertification List, Pg 140 Original policy |
| 67218 | Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; radiation by implantation of source (includes removal of source) | New Hampshire Precertification List, Pg 140 Original policy |
| 67900 | Repair of brow ptosis (supraciliary, mid- forehead or coronal approach) | New Hampshire Precertification List, Pg 140 Original policy |
| 67901 | Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) | New Hampshire Precertification List, Pg 140 Original policy |
| 67902 | Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) | New Hampshire Precertification List, Pg 140 Original policy |
| 67903 | Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach | New Hampshire Precertification List, Pg 140 Original policy |
| 67904 | Repair of blepharoptosis; (tarso) levator resection or advancement, external approach | New Hampshire Precertification List, Pg 140 Original policy |
| 67906 | Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) | New Hampshire Precertification List, Pg 140 Original policy |
| 67908 | Repair of blepharoptosis; conjunctivo- tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type) | New Hampshire Precertification List, Pg 141 Original policy |
| 69090 | Ear piercing | New Hampshire Precertification List, Pg 141 Original policy |
| 69300 | Otoplasty, protruding ear, with or without size reduction | New Hampshire Precertification List, Pg 141 Original policy |
| 69710 | Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone | New Hampshire Precertification List, Pg 141 Original policy |
| 69714 | Implantation, osseointegrated implant, skull; with percutaneous attachment to external speech processor | New Hampshire Precertification List, Pg 141 Original policy |
| 69716 | Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or resulting in removal of less than 100 sq mm surface area of bone deep to the outer cranial cortex | New Hampshire Precertification List, Pg 141 Original policy |
| 69717 | Replacement (including removal of existing device), osseointegrated implant, skull; with percutaneous attachment to external speech processor | New Hampshire Precertification List, Pg 141 Original policy |
| 69719 | Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or involving a bony defect less than 100 sq mm surface area of bone deep to the outer cranial cortex | New Hampshire Precertification List, Pg 141 Original policy |
| 69729 | Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside of the mastoid and resulting in removal of greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex | New Hampshire Precertification List, Pg 141 Original policy |
| 69730 | Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside the mastoid and involving a bony defect greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex | New Hampshire Precertification List, Pg 141 Original policy |
| 69930 | Cochlear device implantation, with or without mastoidectomy | New Hampshire Precertification List, Pg 141 Original policy |
| 69955 | Total facial nerve decompression and/or repair (may include graft) | New Hampshire Precertification List, Pg 141 Original policy |
| 70336 | Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) | New Hampshire Precertification List, Pg 141 Original policy |
| 70450 | Computed tomography, head or brain; without contrast material | New Hampshire Precertification List, Pg 141 Original policy |
| 70460 | Computed tomography, head or brain; with contrast material(s) | New Hampshire Precertification List, Pg 142 Original policy |
| 70470 | Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections | New Hampshire Precertification List, Pg 142 Original policy |
| 70471 | Computed tomographic angiography (CTA | New Hampshire Precertification List, Pg 142 Original policy |
| 70473 | Computed tomographic (CT) cerebral perf | New Hampshire Precertification List, Pg 142 Original policy |
| 70480 | Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material | New Hampshire Precertification List, Pg 142 Original policy |
| 70481 | Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) | New Hampshire Precertification List, Pg 142 Original policy |
| 70482 | Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections | New Hampshire Precertification List, Pg 142 Original policy |
| 70486 | Computed tomography, maxillofacial area; without contrast material | New Hampshire Precertification List, Pg 142 Original policy |
| 70487 | Computed tomography, maxillofacial area; with contrast material(s) | New Hampshire Precertification List, Pg 142 Original policy |
| 70488 | Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections | New Hampshire Precertification List, Pg 142 Original policy |
| 70490 | Computed tomography, soft tissue neck; without contrast material | New Hampshire Precertification List, Pg 142 Original policy |
| 70491 | Computed tomography, soft tissue neck; with contrast material(s) | New Hampshire Precertification List, Pg 142 Original policy |
| 70492 | Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections | New Hampshire Precertification List, Pg 142 Original policy |
| 70496 | Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing | New Hampshire Precertification List, Pg 142 Original policy |
| 70498 | Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing | New Hampshire Precertification List, Pg 142 Original policy |
| 70540 | Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s) | New Hampshire Precertification List, Pg 142 Original policy |
| 70542 | Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s) | New Hampshire Precertification List, Pg 142 Original policy |
| 70543 | Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences | New Hampshire Precertification List, Pg 142 Original policy |
| 70544 | Magnetic resonance angiography, head; without contrast material(s) | New Hampshire Precertification List, Pg 142 Original policy |
| 70545 | Magnetic resonance angiography, head; with contrast material(s) | New Hampshire Precertification List, Pg 143 Original policy |
| 70546 | Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences | New Hampshire Precertification List, Pg 143 Original policy |
| 70547 | Magnetic resonance angiography, neck; without contrast material(s) | New Hampshire Precertification List, Pg 143 Original policy |
| 70548 | Magnetic resonance angiography, neck; with contrast material(s) | New Hampshire Precertification List, Pg 143 Original policy |