Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 35
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 |
|---|---|---|
| 73220 | Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences | New Hampshire Precertification List, Pg 146 Original policy |
| 73221 | Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) | New Hampshire Precertification List, Pg 146 Original policy |
| 73222 | Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s) | New Hampshire Precertification List, Pg 146 Original policy |
| 73223 | Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences | New Hampshire Precertification List, Pg 146 Original policy |
| 73225 | Magnetic resonance angiography, upper extremity, with or without contrast material(s) | New Hampshire Precertification List, Pg 146 Original policy |
| 73700 | Computed tomography, lower extremity; without contrast material | New Hampshire Precertification List, Pg 146 Original policy |
| 73701 | Computed tomography, lower extremity; with contrast material(s) | New Hampshire Precertification List, Pg 146 Original policy |
| 73702 | Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections | New Hampshire Precertification List, Pg 146 Original policy |
| 73706 | Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing | New Hampshire Precertification List, Pg 146 Original policy |
| 73718 | Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) | New Hampshire Precertification List, Pg 146 Original policy |
| 73719 | Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s) | New Hampshire Precertification List, Pg 146 Original policy |
| 73720 | Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences | New Hampshire Precertification List, Pg 146 Original policy |
| 73721 | Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material | New Hampshire Precertification List, Pg 147 Original policy |
| 73722 | Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s) | New Hampshire Precertification List, Pg 147 Original policy |
| 73723 | Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences | New Hampshire Precertification List, Pg 147 Original policy |
| 73725 | Magnetic resonance angiography, lower extremity, with or without contrast material(s) | New Hampshire Precertification List, Pg 147 Original policy |
| 74150 | Computed tomography, abdomen; without contrast material | New Hampshire Precertification List, Pg 147 Original policy |
| 74160 | Computed tomography, abdomen; with contrast material(s) | New Hampshire Precertification List, Pg 147 Original policy |
| 74170 | Ct Scan, Abdomen; W/O Contrast, Then W/Contrast & Further Sections | New Hampshire Precertification List, Pg 147 Original policy |
| 74174 | Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections | New Hampshire Precertification List, Pg 147 Original policy |
| 74175 | Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing | New Hampshire Precertification List, Pg 147 Original policy |
| 74176 | Computed tomography, abdomen and pelvis; without contrast material | New Hampshire Precertification List, Pg 147 Original policy |
| 74177 | Computed tomography, abdomen and pelvis; with contrast material(s) | New Hampshire Precertification List, Pg 147 Original policy |
| 74178 | Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions | New Hampshire Precertification List, Pg 147 Original policy |
| 74181 | Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) | New Hampshire Precertification List, Pg 147 Original policy |
| 74182 | Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s) | New Hampshire Precertification List, Pg 147 Original policy |
| 74183 | Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences | New Hampshire Precertification List, Pg 147 Original policy |
| 74185 | Magnetic resonance angiography, abdomen, with or without contrast material(s) | New Hampshire Precertification List, Pg 147 Original policy |
| 74261 | Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material | New Hampshire Precertification List, Pg 147 Original policy |
| 74262 | Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed | New Hampshire Precertification List, Pg 148 Original policy |
| 74263 | Computed tomographic (CT) colonography, screening, including image postprocessing | New Hampshire Precertification List, Pg 148 Original policy |
| 74712 | Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single of first gestation | New Hampshire Precertification List, Pg 148 Original policy |
| 75557 | Cardiac magnetic resonance imaging for morphology and function without contrast material | New Hampshire Precertification List, Pg 148 Original policy |
| 75559 | Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging | New Hampshire Precertification List, Pg 148 Original policy |
| 75561 | Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences | New Hampshire Precertification List, Pg 148 Original policy |
| 75563 | Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging | New Hampshire Precertification List, Pg 148 Original policy |
| 75571 | Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium | New Hampshire Precertification List, Pg 148 Original policy |
| 75572 | Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) | New Hampshire Precertification List, Pg 148 Original policy |
| 75573 | Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of left ventricular [LV] cardiac function, right ventricular [RV] structure and function and evaluation of vascular structures, if performed) | New Hampshire Precertification List, Pg 148 Original policy |
| 75574 | Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) | New Hampshire Precertification List, Pg 148 Original policy |
| 75580 | Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of the data set from a coronary computed tomography angiography, with interpretation and report by a physician or other qualified health care professional | New Hampshire Precertification List, Pg 149 Original policy |
| 75635 | Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing | New Hampshire Precertification List, Pg 149 Original policy |
| 76120 | Cineradiography/videoradiography, except where specifically included | New Hampshire Precertification List, Pg 149 Original policy |
| 76376 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation | New Hampshire Precertification List, Pg 149 Original policy |
| 76377 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation | New Hampshire Precertification List, Pg 149 Original policy |
| 76390 | Magnetic resonance spectroscopy | New Hampshire Precertification List, Pg 149 Original policy |
| 76391 | Magnetic resonance (eg, vibration) elastography | New Hampshire Precertification List, Pg 149 Original policy |
| 76873 | Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure) | New Hampshire Precertification List, Pg 149 Original policy |
| 76965 | Ultrasonic guidance for interstitial radioelement application | New Hampshire Precertification List, Pg 149 Original policy |
| 77014 | Computed tomography guidance for placement of radiation therapy fields | New Hampshire Precertification List, Pg 149 Original policy |