Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 49
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 |
|---|---|---|
| B5100 | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic-HepatAmine-premix | New Hampshire Precertification List, Pg 210 Original policy |
| B5200 | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-branch chain amino acids-FreAmine-HBC-premix | New Hampshire Precertification List, Pg 210 Original policy |
| B9004 | Parenteral nutrition infusion pump, portable | New Hampshire Precertification List, Pg 210 Original policy |
| B9006 | Parenteral nutrition infusion pump, stationary | New Hampshire Precertification List, Pg 210 Original policy |
| C1605 | Pacemaker, leadless, dual chamber (right atrial and right ventricular implantable components), rate-responsive, including all necessary components for implantation | New Hampshire Precertification List, Pg 210 Original policy |
| C1714 | Catheter, transluminal atherectomy, directional | New Hampshire Precertification List, Pg 210 Original policy |
| C1721 | Cardioverter-defibrillator, dual chamber (implantable) | New Hampshire Precertification List, Pg 210 Original policy |
| C1722 | Cardioverter-defibrillator, single chamber (implantable) | New Hampshire Precertification List, Pg 210 Original policy |
| C1724 | Catheter, transluminal atherectomy, rotational | New Hampshire Precertification List, Pg 210 Original policy |
| C1725 | Catheter, transluminal angioplasty, nonlaser (may include guidance, infusion/perfusion capability) | New Hampshire Precertification List, Pg 210 Original policy |
| C1726 | Catheter, balloon dilatation, nonvascular | New Hampshire Precertification List, Pg 211 Original policy |
| C1734 | Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable) | New Hampshire Precertification List, Pg 211 Original policy |
| C1735 | Catheter(s), intravascular for renal denervation, radiofrequency, including all single-use system components | New Hampshire Precertification List, Pg 211 Original policy |
| C1736 | Catheter(s), intravascular for renal denervation, ultrasound, including all single- use system components | New Hampshire Precertification List, Pg 211 Original policy |
| C1753 | Catheter, intravascular ultrasound | New Hampshire Precertification List, Pg 211 Original policy |
| C1760 | Closure device, vascular (implantable/insertable) | New Hampshire Precertification List, Pg 211 Original policy |
| C1761 | Catheter, transluminal intravascular lithotripsy, coronary | New Hampshire Precertification List, Pg 211 Original policy |
| C1763 | Connective tissue, nonhuman (includes sy | New Hampshire Precertification List, Pg 211 Original policy |
| C1764 | Event recorder, cardiac (implantable) | New Hampshire Precertification List, Pg 211 Original policy |
| C1767 | Generator, neurostimulator (implantable), nonrechargeable | New Hampshire Precertification List, Pg 211 Original policy |
| C1769 | Guide wire | New Hampshire Precertification List, Pg 211 Original policy |
| C1772 | Infusion pump, programmable (implantable) | New Hampshire Precertification List, Pg 211 Original policy |
| C1777 | Lead, cardioverter-defibrillator, endocardial single coil (implantable) | New Hampshire Precertification List, Pg 211 Original policy |
| C1778 | Lead, neurostimulator (implantable) | New Hampshire Precertification List, Pg 211 Original policy |
| C1785 | Pacemaker, dual chamber, rate- responsive (implantable) | New Hampshire Precertification List, Pg 211 Original policy |
| C1786 | Pacemaker, single chamber, rate- responsive (implantable) | New Hampshire Precertification List, Pg 211 Original policy |
| C1787 | Patient programmer, neurostimulator | New Hampshire Precertification List, Pg 211 Original policy |
| C1789 | Prosthesis, breast (implantable) | New Hampshire Precertification List, Pg 211 Original policy |
| C1813 | Prosthesis, penile, inflatable | New Hampshire Precertification List, Pg 211 Original policy |
| C1815 | Prosthesis, urinary sphincter (implantable) | New Hampshire Precertification List, Pg 211 Original policy |
| C1816 | Receiver and/or transmitter, neurostimulator (implantable) | New Hampshire Precertification List, Pg 211 Original policy |
| C1820 | Generator, neurostimulator (implantable), with rechargeable battery and charging system | New Hampshire Precertification List, Pg 211 Original policy |
| C1821 | Interspinous process distraction device (implantable) | New Hampshire Precertification List, Pg 211 Original policy |
| C1822 | Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system | New Hampshire Precertification List, Pg 211 Original policy |
| C1823 | Generator, neurostimulator (implantable), non-rechargeable, with transvenous sensing and stimulation leads | New Hampshire Precertification List, Pg 211 Original policy |
| C1824 | Generator, cardiac contractility modulation (implantable) | New Hampshire Precertification List, Pg 212 Original policy |
| C1825 | Generator, neurostimulator (implantable), non-rechargeable with carotid sinus baroreceptor stimulation lead(s) | New Hampshire Precertification List, Pg 212 Original policy |
| C1832 | Autograft suspension, including cell processing and application, and all system components | New Hampshire Precertification List, Pg 212 Original policy |
| C1833 | Monitor, cardiac, including intracardiac lead and all system components (implantable) | New Hampshire Precertification List, Pg 212 Original policy |
| C1839 | Iris prosthesis | New Hampshire Precertification List, Pg 212 Original policy |
| C1840 | Lens, intraocular (telescopic) | New Hampshire Precertification List, Pg 212 Original policy |
| C1874 | Stent, coated/covered, with delivery system | New Hampshire Precertification List, Pg 212 Original policy |
| C1875 | Stent, coated/covered, without delivery system | New Hampshire Precertification List, Pg 212 Original policy |
| C1876 | Stent, noncoated/noncovered, with delivery system | New Hampshire Precertification List, Pg 212 Original policy |
| C1877 | Stent, noncoated/noncovered, without delivery system | New Hampshire Precertification List, Pg 212 Original policy |
| C1878 | Material for vocal cord medialization, synthetic (implantable) | New Hampshire Precertification List, Pg 212 Original policy |
| C1882 | Cardioverter-defibrillator, other than single or dual chamber (implantable) | New Hampshire Precertification List, Pg 212 Original policy |
| C1883 | Adaptor/extension, pacing lead or neurostimulator lead (implantable) | New Hampshire Precertification List, Pg 212 Original policy |
| C1885 | Catheter, transluminal angioplasty, laser | New Hampshire Precertification List, Pg 212 Original policy |
| C1887 | Catheter, guiding (may include infusion/perfusion capability) | New Hampshire Precertification List, Pg 212 Original policy |