Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 36
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 |
|---|---|---|
| 77046 | Magnetic resonance imaging, breast, without contrast material; unilateral | New Hampshire Precertification List, Pg 149 Original policy |
| 77047 | Magnetic resonance imaging, breast, without contrast material; bilateral | New Hampshire Precertification List, Pg 149 Original policy |
| 77048 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral | New Hampshire Precertification List, Pg 149 Original policy |
| 77049 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral | New Hampshire Precertification List, Pg 150 Original policy |
| 77078 | Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) | New Hampshire Precertification List, Pg 150 Original policy |
| 77084 | Magnetic resonance (eg, proton) imaging, bone marrow blood supply | New Hampshire Precertification List, Pg 150 Original policy |
| 77295 | 3-dimensional radiotherapy plan, including dose-volume histograms | New Hampshire Precertification List, Pg 150 Original policy |
| 77301 | Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications | New Hampshire Precertification List, Pg 150 Original policy |
| 77316 | Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s) | New Hampshire Precertification List, Pg 150 Original policy |
| 77317 | Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s) | New Hampshire Precertification List, Pg 150 Original policy |
| 77318 | Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) | New Hampshire Precertification List, Pg 150 Original policy |
| 77338 | Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan | New Hampshire Precertification List, Pg 150 Original policy |
| 77370 | Special medical radiation physics consultation | New Hampshire Precertification List, Pg 150 Original policy |
| 77371 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based | New Hampshire Precertification List, Pg 150 Original policy |
| 77372 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based | New Hampshire Precertification List, Pg 150 Original policy |
| 77373 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions | New Hampshire Precertification List, Pg 150 Original policy |
| 77385 | Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple | New Hampshire Precertification List, Pg 150 Original policy |
| 77386 | Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex | New Hampshire Precertification List, Pg 151 Original policy |
| 77387 | Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed | New Hampshire Precertification List, Pg 151 Original policy |
| 77402 | Radiation treatment delivery, => 1 MeV; simple | New Hampshire Precertification List, Pg 151 Original policy |
| 77407 | Radiation treatment delivery, => 1 MeV; intermediate | New Hampshire Precertification List, Pg 151 Original policy |
| 77412 | Radiation treatment delivery, => 1 MeV; complex | New Hampshire Precertification List, Pg 151 Original policy |
| 77423 | High energy neutron radiation treatment delivery, 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) | New Hampshire Precertification List, Pg 151 Original policy |
| 77424 | Intraoperative radiation treatment delivery, x-ray, single treatment session | New Hampshire Precertification List, Pg 151 Original policy |
| 77425 | Intraoperative radiation treatment delivery, electrons, single treatment session | New Hampshire Precertification List, Pg 151 Original policy |
| 77432 | Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) | New Hampshire Precertification List, Pg 151 Original policy |
| 77435 | Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions | New Hampshire Precertification List, Pg 151 Original policy |
| 77436 | Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting | New Hampshire Precertification List, Pg 151 Original policy |
| 77437 | Surface radiation therapy; superficial, delivery, =150 kV, per fraction (eg, electronic brachytherapy) | New Hampshire Precertification List, Pg 151 Original policy |
| 77438 | Surface radiation therapy; orthovoltage, delivery, >150-500 kV, per fraction | New Hampshire Precertification List, Pg 151 Original policy |
| 77439 | Surface radiation therapy; superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for treatment of cutaneous tumors, per course of t | New Hampshire Precertification List, Pg 151 Original policy |
| 77469 | Intraoperative radiation treatment management | New Hampshire Precertification List, Pg 151 Original policy |
| 77470 | Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation) | New Hampshire Precertification List, Pg 151 Original policy |
| 77520 | Proton treatment delivery; simple, without compensation | New Hampshire Precertification List, Pg 151 Original policy |
| 77522 | Proton treatment delivery; simple, with compensation | New Hampshire Precertification List, Pg 151 Original policy |
| 77523 | Proton treatment delivery; intermediate | New Hampshire Precertification List, Pg 152 Original policy |
| 77525 | Proton treatment delivery; complex | New Hampshire Precertification List, Pg 152 Original policy |
| 77761 | Intracavitary radiation source application; simple | New Hampshire Precertification List, Pg 152 Original policy |
| 77762 | Intracavitary radiation source application; intermediate | New Hampshire Precertification List, Pg 152 Original policy |
| 77763 | Intracavitary radiation source application; complex | New Hampshire Precertification List, Pg 152 Original policy |
| 77770 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel | New Hampshire Precertification List, Pg 152 Original policy |
| 77771 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels | New Hampshire Precertification List, Pg 152 Original policy |
| 77772 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels | New Hampshire Precertification List, Pg 152 Original policy |
| 77778 | Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed | New Hampshire Precertification List, Pg 152 Original policy |
| 77790 | Supervision, handling, loading of radiation source | New Hampshire Precertification List, Pg 152 Original policy |
| 78429 | Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan | New Hampshire Precertification List, Pg 152 Original policy |
| 78430 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan | New Hampshire Precertification List, Pg 152 Original policy |
| 78431 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan | New Hampshire Precertification List, Pg 152 Original policy |
| 78432 | Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability) | New Hampshire Precertification List, Pg 153 Original policy |
| 78433 | Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently acquired computed tomography transmission scan | New Hampshire Precertification List, Pg 153 Original policy |