Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 45
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 |
|---|---|---|
| 93621 | Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 190 Original policy |
| 93622 | Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 191 Original policy |
| 93624 | Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction of arrhythmia | New Hampshire Precertification List, Pg 191 Original policy |
| 93640 | Electrophysiologic evaluation of single or dual chamber pacing cardioverter- defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement | New Hampshire Precertification List, Pg 191 Original policy |
| 93641 | Electrophysiologic evaluation of single or dual chamber pacing cardioverter- defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator | New Hampshire Precertification List, Pg 191 Original policy |
| 93650 | Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement | New Hampshire Precertification List, Pg 191 Original policy |
| 93653 | Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3- dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry | New Hampshire Precertification List, Pg 192 Original policy |
| 93654 | Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3- dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of ventricular tachycardia or focus of ventricular ectopy including left ventricular pacing and recording, when performed | New Hampshire Precertification List, Pg 192 Original policy |
| 93655 | Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 192 Original policy |
| 93656 | Comprehensive electrophysiologic evaluation with transseptal catheterizations, insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, and intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3- dimensional mapping, intracardiac echocardiography with imaging supervision and interpretation, right ventricular pacing/recording, and His bundle recording, when performed | New Hampshire Precertification List, Pg 193 Original policy |
| 93657 | Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 193 Original policy |
| 93701 | Bioimpedance-derived physiologic cardiovascular analysis | New Hampshire Precertification List, Pg 193 Original policy |
| 93702 | Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s) | New Hampshire Precertification List, Pg 193 Original policy |
| 93745 | Initial set-up and programming by a physician or other qualified health care professional of wearable cardioverter- defibrillator includes initial programming of system, establishing baseline electronic ECG, transmission of data to data repository, patient instruction in wearing system and patient reporting of problems or events | New Hampshire Precertification List, Pg 193 Original policy |
| 93880 | Duplex scan of extracranial arteries; complete bilateral study | New Hampshire Precertification List, Pg 193 Original policy |
| 93882 | Duplex scan of extracranial arteries; unilateral or limited study | New Hampshire Precertification List, Pg 193 Original policy |
| 93922 | Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2 levels) | New Hampshire Precertification List, Pg 194 Original policy |
| 93923 | Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with reactive hyperemia) | New Hampshire Precertification List, Pg 194 Original policy |
| 93924 | Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study | New Hampshire Precertification List, Pg 194 Original policy |
| 93925 | Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study | New Hampshire Precertification List, Pg 195 Original policy |
| 93926 | Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study | New Hampshire Precertification List, Pg 195 Original policy |
| 93930 | Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study | New Hampshire Precertification List, Pg 195 Original policy |
| 93931 | Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study | New Hampshire Precertification List, Pg 195 Original policy |
| 93978 | Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study | New Hampshire Precertification List, Pg 195 Original policy |
| 93979 | Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study | New Hampshire Precertification List, Pg 195 Original policy |
| 94667 | Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation | New Hampshire Precertification List, Pg 195 Original policy |
| 94668 | Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent | New Hampshire Precertification List, Pg 195 Original policy |
| 95782 | Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist | New Hampshire Precertification List, Pg 195 Original policy |
| 95783 | Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist | New Hampshire Precertification List, Pg 195 Original policy |
| 95800 | Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time | New Hampshire Precertification List, Pg 195 Original policy |
| 95801 | Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone) | New Hampshire Precertification List, Pg 195 Original policy |
| 95803 | Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording) | New Hampshire Precertification List, Pg 195 Original policy |
| 95805 | Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness | New Hampshire Precertification List, Pg 195 Original policy |
| 95806 | Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) | New Hampshire Precertification List, Pg 196 Original policy |
| 95807 | Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist | New Hampshire Precertification List, Pg 196 Original policy |
| 95808 | Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist | New Hampshire Precertification List, Pg 196 Original policy |
| 95810 | Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist | New Hampshire Precertification List, Pg 196 Original policy |
| 95811 | Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist | New Hampshire Precertification List, Pg 196 Original policy |
| 95905 | Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report | New Hampshire Precertification List, Pg 196 Original policy |
| 95965 | Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (eg, epileptic cerebral cortex localization) | New Hampshire Precertification List, Pg 196 Original policy |
| 95966 | Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, single modality (eg, sensory, motor, language, or visual cortex localization) | New Hampshire Precertification List, Pg 196 Original policy |
| 95967 | Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, each additional modality (eg, sensory, motor, language, or visual cortex localization) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 196 Original policy |
| 95976 | Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional | New Hampshire Precertification List, Pg 197 Original policy |
| 95977 | Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional | New Hampshire Precertification List, Pg 197 Original policy |
| 96001 | Comprehensive computer-based motion analysis by video-taping and 3D kinematics; with dynamic plantar pressure measurements during walking | New Hampshire Precertification List, Pg 197 Original policy |
| 96365 | Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour | New Hampshire Precertification List, Pg 197 Original policy |
| 96372 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular | New Hampshire Precertification List, Pg 197 Original policy |
| 96904 | Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma | New Hampshire Precertification List, Pg 197 Original policy |
| 96931 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion | New Hampshire Precertification List, Pg 197 Original policy |
| 96932 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, first lesion | New Hampshire Precertification List, Pg 198 Original policy |