Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 44
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 |
|---|---|---|
| 92610 | Evaluation of oral and pharyngeal swallowing function | New Hampshire Precertification List, Pg 185 Original policy |
| 92611 | Motion fluoroscopic evaluation of swallowing function by cine or video recording | New Hampshire Precertification List, Pg 185 Original policy |
| 92618 | Evaluation for prescription of non-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 |
| 92626 | Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); first hour | New Hampshire Precertification List, Pg 185 Original policy |
| 92627 | Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); each additional 15 minutes (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 185 Original policy |
| 92630 | Auditory rehabilitation; prelingual hearing loss | New Hampshire Precertification List, Pg 185 Original policy |
| 92633 | Auditory rehabilitation; post-lingual hearing loss | New Hampshire Precertification List, Pg 185 Original policy |
| 92920 | Percutaneous transluminal coronary angioplasty; single major coronary artery or branch | New Hampshire Precertification List, Pg 185 Original policy |
| 92924 | Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery or branch | New Hampshire Precertification List, Pg 186 Original policy |
| 92928 | Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch | New Hampshire Precertification List, Pg 186 Original policy |
| 92933 | Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch | New Hampshire Precertification List, Pg 186 Original policy |
| 92937 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel | New Hampshire Precertification List, Pg 186 Original policy |
| 92943 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel | New Hampshire Precertification List, Pg 186 Original policy |
| 92975 | Thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography | New Hampshire Precertification List, Pg 186 Original policy |
| 93150 | Therapy activation of implanted phrenic nerve stimulator system, including all interrogation and programming | New Hampshire Precertification List, Pg 186 Original policy |
| 93151 | Interrogation and programming (minimum one parameter) of implanted phrenic nerve stimulator system | New Hampshire Precertification List, Pg 186 Original policy |
| 93152 | Interrogation and programming of implanted phrenic nerve stimulator system during polysomnography | New Hampshire Precertification List, Pg 186 Original policy |
| 93153 | Interrogation without programming of implanted phrenic nerve stimulator system | New Hampshire Precertification List, Pg 186 Original policy |
| 93228 | External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional | New Hampshire Precertification List, Pg 186 Original policy |
| 93229 | External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional | New Hampshire Precertification List, Pg 187 Original policy |
| 93264 | Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure recordings, interpretation(s), trend analysis, and report(s) by a physician or other qualified health care professional | New Hampshire Precertification List, Pg 187 Original policy |
| 93303 | Transthoracic echocardiography for congenital cardiac anomalies; complete | New Hampshire Precertification List, Pg 187 Original policy |
| 93304 | Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study | New Hampshire Precertification List, Pg 187 Original policy |
| 93306 | Echocardiography, transthoracic, real- time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography | New Hampshire Precertification List, Pg 187 Original policy |
| 93307 | Echocardiography, transthoracic, real- time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography | New Hampshire Precertification List, Pg 187 Original policy |
| 93308 | Echocardiography, transthoracic, real- time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study | New Hampshire Precertification List, Pg 187 Original policy |
| 93312 | Echocardiography, transesophageal, real- time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report | New Hampshire Precertification List, Pg 187 Original policy |
| 93313 | Echocardiography, transesophageal, real- time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only | New Hampshire Precertification List, Pg 187 Original policy |
| 93314 | Echocardiography, transesophageal, real- time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only | New Hampshire Precertification List, Pg 188 Original policy |
| 93315 | Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report | New Hampshire Precertification List, Pg 188 Original policy |
| 93316 | Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only | New Hampshire Precertification List, Pg 188 Original policy |
| 93317 | Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only | New Hampshire Precertification List, Pg 188 Original policy |
| 93350 | Echocardiography, transthoracic, real- time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report | New Hampshire Precertification List, Pg 188 Original policy |
| 93351 | Echocardiography, transthoracic, real- time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional | New Hampshire Precertification List, Pg 188 Original policy |
| 93454 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation | New Hampshire Precertification List, Pg 188 Original policy |
| 93455 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography | New Hampshire Precertification List, Pg 188 Original policy |
| 93456 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization | New Hampshire Precertification List, Pg 189 Original policy |
| 93457 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization | New Hampshire Precertification List, Pg 189 Original policy |
| 93458 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed | New Hampshire Precertification List, Pg 189 Original policy |
| 93459 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography | New Hampshire Precertification List, Pg 189 Original policy |
| 93460 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed | New Hampshire Precertification List, Pg 189 Original policy |
| 93461 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography | New Hampshire Precertification List, Pg 190 Original policy |
| 93580 | Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant | New Hampshire Precertification List, Pg 190 Original policy |
| 93600 | Bundle of His recording | New Hampshire Precertification List, Pg 190 Original policy |
| 93602 | Intra-atrial recording | New Hampshire Precertification List, Pg 190 Original policy |
| 93603 | Right ventricular recording | New Hampshire Precertification List, Pg 190 Original policy |
| 93609 | Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 190 Original policy |
| 93613 | Intracardiac electrophysiologic 3- dimensional mapping (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 190 Original policy |
| 93619 | Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia | New Hampshire Precertification List, Pg 190 Original policy |
| 93620 | Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording | New Hampshire Precertification List, Pg 190 Original policy |