Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 43
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 |
|---|---|---|
| 83520 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified | New Hampshire Precertification List, Pg 182 Original policy |
| 83884 | Neurofilament light chain (NfL) | New Hampshire Precertification List, Pg 182 Original policy |
| 83921 | Organic Acid, Single, Quantitative | New Hampshire Precertification List, Pg 182 Original policy |
| 84393 | Tau, phosphorylated (eg, pTau 181, pTau 217) | New Hampshire Precertification List, Pg 182 Original policy |
| 84394 | Tau, total (tTau) | New Hampshire Precertification List, Pg 182 Original policy |
| 86001 | Allergen specific IgG quantitative or semiquantitative, each allergen | New Hampshire Precertification List, Pg 182 Original policy |
| 86343 | Leukocyte histamine release test (LHR) | New Hampshire Precertification List, Pg 182 Original policy |
| 86352 | Cellular function assay involving stimulation (eg, mitogen or antigen) and detection of biomarker (eg, ATP) | New Hampshire Precertification List, Pg 182 Original policy |
| 86357 | Natural killer (NK) cells, total count | New Hampshire Precertification List, Pg 182 Original policy |
| 88356 | Morphometric analysis; nerve | New Hampshire Precertification List, Pg 182 Original policy |
| 89250 | Culture of oocyte(s)/embryo(s), less than 4 days | New Hampshire Precertification List, Pg 182 Original policy |
| 89251 | Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos | New Hampshire Precertification List, Pg 183 Original policy |
| 89253 | Assisted embryo hatching, microtechniques (any method) | New Hampshire Precertification List, Pg 183 Original policy |
| 89254 | Oocyte identification from follicular fluid | New Hampshire Precertification List, Pg 183 Original policy |
| 89255 | Preparation of embryo for transfer (any method) | New Hampshire Precertification List, Pg 183 Original policy |
| 89268 | Insemination of oocytes | New Hampshire Precertification List, Pg 183 Original policy |
| 89272 | Extended culture of oocyte(s)/embryo(s), 4-7 days | New Hampshire Precertification List, Pg 183 Original policy |
| 89329 | Sperm evaluation; hamster penetration test | New Hampshire Precertification List, Pg 183 Original policy |
| 89330 | Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test | New Hampshire Precertification List, Pg 183 Original policy |
| 89344 | Storage (per year); reproductive tissue, testicular/ovarian | New Hampshire Precertification List, Pg 183 Original policy |
| 89346 | Storage (per year); oocyte(s) | New Hampshire Precertification List, Pg 183 Original policy |
| 89354 | Thawing of cryopreserved; reproductive tissue, testicular/ovarian | New Hampshire Precertification List, Pg 183 Original policy |
| 89356 | Thawing of cryopreserved; oocytes, each aliquot | New Hampshire Precertification List, Pg 183 Original policy |
| 90281 | Immune globulin (Ig), human, for intramuscular use | New Hampshire Precertification List, Pg 183 Original policy |
| 90283 | Immune globulin (IgIV), human, for intravenous use | New Hampshire Precertification List, Pg 183 Original policy |
| 90284 | Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each | New Hampshire Precertification List, Pg 183 Original policy |
| 90378 | Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each | New Hampshire Precertification List, Pg 183 Original policy |
| 90380 | Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use | New Hampshire Precertification List, Pg 183 Original policy |
| 90381 | Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use | New Hampshire Precertification List, Pg 183 Original policy |
| 90867 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management | New Hampshire Precertification List, Pg 183 Original policy |
| 90868 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session | New Hampshire Precertification List, Pg 183 Original policy |
| 90869 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re- determination with delivery and management | New Hampshire Precertification List, Pg 183 Original policy |
| 90875 | Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes | New Hampshire Precertification List, Pg 184 Original policy |
| 90876 | Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 45 minutes | New Hampshire Precertification List, Pg 184 Original policy |
| 90901 | Biofeedback training by any modality | New Hampshire Precertification List, Pg 184 Original policy |
| 90912 | Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on- one physician or other qualified health care professional contact with the patient | New Hampshire Precertification List, Pg 184 Original policy |
| 90913 | Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 184 Original policy |
| 91112 | Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report | New Hampshire Precertification List, Pg 184 Original policy |
| 92507 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual | New Hampshire Precertification List, Pg 184 Original policy |
| 92508 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals | New Hampshire Precertification List, Pg 184 Original policy |
| 92521 | Evaluation of speech fluency (eg, stuttering, cluttering) | New Hampshire Precertification List, Pg 184 Original policy |
| 92522 | Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria) | New Hampshire Precertification List, Pg 184 Original policy |
| 92523 | Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) | New Hampshire Precertification List, Pg 184 Original policy |
| 92524 | Behavioral and qualitative analysis of voice and resonance | New Hampshire Precertification List, Pg 184 Original policy |
| 92526 | Treatment of swallowing dysfunction and/or oral function for feeding | New Hampshire Precertification List, Pg 184 Original policy |
| 92605 | Evaluation for prescription of non-speech- generating augmentative and alternative communication device, face-to-face with the patient; first hour | New Hampshire Precertification List, Pg 185 Original policy |
| 92606 | Therapeutic service(s) for the use of non- speech-generating device, including programming and modification | New Hampshire Precertification List, Pg 185 Original policy |
| 92607 | Evaluation for prescription for speech- generating augmentative and alternative communication device, face-to-face with the patient; first hour | New Hampshire Precertification List, Pg 185 Original policy |
| 92608 | Evaluation for prescription for speech- generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 185 Original policy |
| 92609 | Therapeutic services for the use of speech-generating device, including programming and modification | New Hampshire Precertification List, Pg 185 Original policy |