Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 37
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 |
|---|---|---|
| 78451 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) | New Hampshire Precertification List, Pg 153 Original policy |
| 78452 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection | New Hampshire Precertification List, Pg 153 Original policy |
| 78453 | Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) | New Hampshire Precertification List, Pg 153 Original policy |
| 78454 | Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection | New Hampshire Precertification List, Pg 153 Original policy |
| 78459 | Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study | New Hampshire Precertification List, Pg 153 Original policy |
| 78466 | Myocardial imaging, infarct avid, planar; qualitative or quantitative | New Hampshire Precertification List, Pg 154 Original policy |
| 78468 | Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique | New Hampshire Precertification List, Pg 154 Original policy |
| 78469 | Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification | New Hampshire Precertification List, Pg 154 Original policy |
| 78472 | Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing | New Hampshire Precertification List, Pg 154 Original policy |
| 78473 | Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification | New Hampshire Precertification List, Pg 154 Original policy |
| 78481 | Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification | New Hampshire Precertification List, Pg 154 Original policy |
| 78483 | Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification | New Hampshire Precertification List, Pg 154 Original policy |
| 78491 | 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) | New Hampshire Precertification List, Pg 154 Original policy |
| 78492 | 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) | New Hampshire Precertification List, Pg 154 Original policy |
| 78494 | Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing | New Hampshire Precertification List, Pg 154 Original policy |
| 78608 | Brain imaging, positron emission tomography (PET); metabolic evaluation | New Hampshire Precertification List, Pg 154 Original policy |
| 78609 | Brain imaging, positron emission tomography (PET); perfusion evaluation | New Hampshire Precertification List, Pg 154 Original policy |
| 78811 | Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck) | New Hampshire Precertification List, Pg 155 Original policy |
| 78812 | Positron emission tomography (PET) imaging; skull base to mid-thigh | New Hampshire Precertification List, Pg 155 Original policy |
| 78813 | Positron emission tomography (PET) imaging; whole body | New Hampshire Precertification List, Pg 155 Original policy |
| 78814 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) | New Hampshire Precertification List, Pg 155 Original policy |
| 78815 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh | New Hampshire Precertification List, Pg 155 Original policy |
| 78816 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body | New Hampshire Precertification List, Pg 155 Original policy |
| 79101 | Radiopharmaceutical therapy, by intravenous administration | New Hampshire Precertification List, Pg 155 Original policy |
| 79403 | Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion | New Hampshire Precertification List, Pg 155 Original policy |
| 81120 | IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg, glioma), common variants (eg, R132H, R132C) | New Hampshire Precertification List, Pg 155 Original policy |
| 81121 | IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (eg, glioma), common variants (eg, R140W, R172M) | New Hampshire Precertification List, Pg 155 Original policy |
| 81161 | DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed | New Hampshire Precertification List, Pg 155 Original policy |
| 81162 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements) | New Hampshire Precertification List, Pg 155 Original policy |
| 81163 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis | New Hampshire Precertification List, Pg 155 Original policy |
| 81164 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) | New Hampshire Precertification List, Pg 156 Original policy |
| 81165 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis | New Hampshire Precertification List, Pg 156 Original policy |
| 81166 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) | New Hampshire Precertification List, Pg 156 Original policy |
| 81167 | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) | New Hampshire Precertification List, Pg 156 Original policy |
| 81170 | ABL1 (ABL proto-oncogene 1, non- receptor tyrosine kinase) (eg, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain | New Hampshire Precertification List, Pg 156 Original policy |
| 81171 | AFF2 (ALF transcription elongation factor 2 [FMR2]) (eg, fragile X intellectual disability 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 156 Original policy |
| 81172 | AFF2 (ALF transcription elongation factor 2 [FMR2]) (eg, fragile X intellectual disability 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methylation status) | New Hampshire Precertification List, Pg 156 Original policy |
| 81173 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence | New Hampshire Precertification List, Pg 156 Original policy |
| 81174 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant | New Hampshire Precertification List, Pg 156 Original policy |
| 81175 | ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; full gene sequence | New Hampshire Precertification List, Pg 156 Original policy |
| 81176 | ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; targeted sequence analysis (eg, exon 12) | New Hampshire Precertification List, Pg 157 Original policy |
| 81177 | ATN1 (atrophin 1) (eg, dentatorubral- pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 157 Original policy |
| 81178 | ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 157 Original policy |
| 81179 | ATXN2 (ataxin 2) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 157 Original policy |
| 81180 | ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 157 Original policy |
| 81181 | ATXN7 (ataxin 7) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 157 Original policy |
| 81182 | ATXN8OS (ATXN8 opposite strand [non- protein coding]) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 157 Original policy |
| 81183 | ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 157 Original policy |
| 81184 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 157 Original policy |
| 81185 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence | New Hampshire Precertification List, Pg 157 Original policy |