Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 34
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 |
|---|---|---|
| 70549 | Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences | New Hampshire Precertification List, Pg 143 Original policy |
| 70551 | Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material | New Hampshire Precertification List, Pg 143 Original policy |
| 70552 | Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) | New Hampshire Precertification List, Pg 143 Original policy |
| 70553 | Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences | New Hampshire Precertification List, Pg 143 Original policy |
| 70554 | Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration | New Hampshire Precertification List, Pg 143 Original policy |
| 70555 | Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing | New Hampshire Precertification List, Pg 143 Original policy |
| 71250 | Computed tomography, thorax, diagnostic; without contrast material | New Hampshire Precertification List, Pg 143 Original policy |
| 71260 | Computed tomography, thorax, diagnostic; with contrast material(s) | New Hampshire Precertification List, Pg 143 Original policy |
| 71270 | Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further sections | New Hampshire Precertification List, Pg 143 Original policy |
| 71271 | Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) | New Hampshire Precertification List, Pg 143 Original policy |
| 71275 | Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing | New Hampshire Precertification List, Pg 143 Original policy |
| 71550 | Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) | New Hampshire Precertification List, Pg 143 Original policy |
| 71551 | Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s) | New Hampshire Precertification List, Pg 144 Original policy |
| 71552 | Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences | New Hampshire Precertification List, Pg 144 Original policy |
| 71555 | Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) | New Hampshire Precertification List, Pg 144 Original policy |
| 72125 | Computed tomography, cervical spine; without contrast material | New Hampshire Precertification List, Pg 144 Original policy |
| 72126 | Computed tomography, cervical spine; with contrast material | New Hampshire Precertification List, Pg 144 Original policy |
| 72127 | Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections | New Hampshire Precertification List, Pg 144 Original policy |
| 72128 | Computed tomography, thoracic spine; without contrast material | New Hampshire Precertification List, Pg 144 Original policy |
| 72129 | Computed tomography, thoracic spine; with contrast material | New Hampshire Precertification List, Pg 144 Original policy |
| 72130 | Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections | New Hampshire Precertification List, Pg 144 Original policy |
| 72131 | Computed tomography, lumbar spine; without contrast material | New Hampshire Precertification List, Pg 144 Original policy |
| 72132 | Computed tomography, lumbar spine; with contrast material | New Hampshire Precertification List, Pg 144 Original policy |
| 72133 | Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections | New Hampshire Precertification List, Pg 144 Original policy |
| 72141 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material | New Hampshire Precertification List, Pg 144 Original policy |
| 72142 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) | New Hampshire Precertification List, Pg 144 Original policy |
| 72146 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material | New Hampshire Precertification List, Pg 144 Original policy |
| 72147 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) | New Hampshire Precertification List, Pg 144 Original policy |
| 72148 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material | New Hampshire Precertification List, Pg 144 Original policy |
| 72149 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) | New Hampshire Precertification List, Pg 144 Original policy |
| 72156 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical | New Hampshire Precertification List, Pg 145 Original policy |
| 72157 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic | New Hampshire Precertification List, Pg 145 Original policy |
| 72158 | Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar | New Hampshire Precertification List, Pg 145 Original policy |
| 72159 | Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s) | New Hampshire Precertification List, Pg 145 Original policy |
| 72191 | Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing | New Hampshire Precertification List, Pg 145 Original policy |
| 72192 | Computed tomography, pelvis; without contrast material | New Hampshire Precertification List, Pg 145 Original policy |
| 72193 | Computed tomography, pelvis; with contrast material(s) | New Hampshire Precertification List, Pg 145 Original policy |
| 72194 | Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections | New Hampshire Precertification List, Pg 145 Original policy |
| 72195 | Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s) | New Hampshire Precertification List, Pg 145 Original policy |
| 72196 | Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) | New Hampshire Precertification List, Pg 145 Original policy |
| 72197 | Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences | New Hampshire Precertification List, Pg 145 Original policy |
| 72198 | Magnetic resonance angiography, pelvis, with or without contrast material(s) | New Hampshire Precertification List, Pg 145 Original policy |
| 72285 | Discography, cervical or thoracic, radiological supervision and interpretation | New Hampshire Precertification List, Pg 145 Original policy |
| 72295 | Discography, lumbar, radiological supervision and interpretation | New Hampshire Precertification List, Pg 145 Original policy |
| 73200 | Computed tomography, upper extremity; without contrast material | New Hampshire Precertification List, Pg 145 Original policy |
| 73201 | Computed tomography, upper extremity; with contrast material(s) | New Hampshire Precertification List, Pg 145 Original policy |
| 73202 | Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections | New Hampshire Precertification List, Pg 145 Original policy |
| 73206 | Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing | New Hampshire Precertification List, Pg 146 Original policy |
| 73218 | Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s) | New Hampshire Precertification List, Pg 146 Original policy |
| 73219 | Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s) | New Hampshire Precertification List, Pg 146 Original policy |