Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 47
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 |
|---|---|---|
| 97760 | Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes | New Hampshire Precertification List, Pg 205 Original policy |
| 97761 | Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes | New Hampshire Precertification List, Pg 205 Original policy |
| 97763 | Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes | New Hampshire Precertification List, Pg 205 Original policy |
| 99183 | Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session | New Hampshire Precertification List, Pg 206 Original policy |
| A0430 | Ambulance service, conventional air services, transport, one way (fixed wing) | New Hampshire Precertification List, Pg 206 Original policy |
| A0431 | Ambulance service, conventional air services, transport, one way (rotary wing) | New Hampshire Precertification List, Pg 206 Original policy |
| A0435 | Fixed wing air mileage, per statute mile | New Hampshire Precertification List, Pg 206 Original policy |
| A0436 | Rotary wing air mileage, per statute mile | New Hampshire Precertification List, Pg 206 Original policy |
| A0888 | Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) | New Hampshire Precertification List, Pg 206 Original policy |
| A2001 | InnovaMatrix AC, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2002 | Mirragen Advanced Wound Matrix, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2004 | XCelliStem, 1 mg | New Hampshire Precertification List, Pg 206 Original policy |
| A2005 | Microlyte Matrix, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2006 | NovoSorb SynPath dermal matrix, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2007 | Restrata, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2008 | TheraGenesis, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2009 | Symphony, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2010 | Apis, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2011 | Supra SDRM, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2012 | SUPRATHEL, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2013 | InnovaMatrix FS, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2014 | Omeza Collagen Matrix, per 100 mg | New Hampshire Precertification List, Pg 206 Original policy |
| A2015 | Phoenix Wound Matrix, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2016 | PermeaDerm B, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2017 | PermeaDerm Glove, each | New Hampshire Precertification List, Pg 206 Original policy |
| A2018 | PermeaDerm C, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2019 | Kerecis Omega3 MariGen Shield, per sq cm | New Hampshire Precertification List, Pg 206 Original policy |
| A2020 | AC5 Advanced Wound System (AC5) | New Hampshire Precertification List, Pg 206 Original policy |
| A2021 | NeoMatriX, per sq cm | New Hampshire Precertification List, Pg 207 Original policy |
| A2022 | InnovaBurn or InnovaMatrix XL, per sq cm | New Hampshire Precertification List, Pg 207 Original policy |
| A2023 | InnovaMatrix PD, 1 mg | New Hampshire Precertification List, Pg 207 Original policy |
| A2024 | Resolve Matrix or XenoPatch, per sq cm | New Hampshire Precertification List, Pg 207 Original policy |
| A2025 | Miro3D, per cu cm | New Hampshire Precertification List, Pg 207 Original policy |
| A2026 | Restrata MiniMatrix, 5 mg | New Hampshire Precertification List, Pg 207 Original policy |
| A2027 | Matriderm, per square centimeter | New Hampshire Precertification List, Pg 207 Original policy |
| A2028 | Micromatrix flex, per mg | New Hampshire Precertification List, Pg 207 Original policy |
| A2029 | Mirotract wound matrix sheet, per cubic centimeter | New Hampshire Precertification List, Pg 207 Original policy |
| A2030 | Miro3D fibers, per mg | New Hampshire Precertification List, Pg 207 Original policy |
| A2031 | MiroDry Wound Matrix, per sq cm | New Hampshire Precertification List, Pg 207 Original policy |
| A2032 | Myriad Matrix, per sq cm | New Hampshire Precertification List, Pg 207 Original policy |
| A2033 | Myriad Morcells, 4 mg | New Hampshire Precertification List, Pg 207 Original policy |
| A2034 | Foundation DRS Solo, per sq cm | New Hampshire Precertification List, Pg 207 Original policy |
| A2035 | Corplex P or Theracor P or Allacor P, per | New Hampshire Precertification List, Pg 207 Original policy |
| A4100 | Skin substitute, FDA-cleared as a device, not otherwise specified | New Hampshire Precertification List, Pg 207 Original policy |
| A4341 | Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each | New Hampshire Precertification List, Pg 207 Original policy |
| A4342 | Accessories for patient inserted indwelling intraurethral drainage device with valve, replacement only, each | New Hampshire Precertification List, Pg 207 Original policy |
| A4438 | Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each | New Hampshire Precertification List, Pg 207 Original policy |
| A4468 | Exsufflation belt, includes all supplies and accessories | New Hampshire Precertification List, Pg 207 Original policy |
| A4540 | Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm | New Hampshire Precertification List, Pg 207 Original policy |
| A4542 | Supplies and accessories for external upper limb tremor stimulator of the peripheral nerves of the wrist | New Hampshire Precertification List, Pg 207 Original policy |