Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 50
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 |
|---|---|---|
| C1891 | Infusion pump, nonprogrammable, permanent (implantable) | New Hampshire Precertification List, Pg 212 Original policy |
| C1895 | Lead, cardioverter-defibrillator, endocardial dual coil (implantable) | New Hampshire Precertification List, Pg 212 Original policy |
| C1896 | Lead, cardioverter-defibrillator, other than endocardial single or dual coil (implantable) | New Hampshire Precertification List, Pg 212 Original policy |
| C2614 | Probe, percutaneous lumbar discectomy | New Hampshire Precertification List, Pg 212 Original policy |
| C2619 | Pacemaker, dual chamber, nonrate- responsive (implantable) | New Hampshire Precertification List, Pg 212 Original policy |
| C2620 | Pacemaker, single chamber, nonrate- responsive (implantable) | New Hampshire Precertification List, Pg 212 Original policy |
| C2621 | Pacemaker, other than single or dual chamber (implantable) | New Hampshire Precertification List, Pg 212 Original policy |
| C2622 | Prosthesis, penile, noninflatable | New Hampshire Precertification List, Pg 212 Original policy |
| C2624 | Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components | New Hampshire Precertification List, Pg 212 Original policy |
| C2626 | Infusion pump, nonprogrammable, temporary (implantable) | New Hampshire Precertification List, Pg 212 Original policy |
| C5271 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | New Hampshire Precertification List, Pg 213 Original policy |
| C5272 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 213 Original policy |
| C5273 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | New Hampshire Precertification List, Pg 213 Original policy |
| C5274 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 213 Original policy |
| C5275 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | New Hampshire Precertification List, Pg 213 Original policy |
| C5276 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 213 Original policy |
| C5277 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | New Hampshire Precertification List, Pg 213 Original policy |
| C5278 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 214 Original policy |
| C7513 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, with transluminal balloon angioplasty of central dialysis segment, performed through dialysis circuit, including all required imaging, radiological supervision and interpretation, image documentation and report | New Hampshire Precertification List, Pg 214 Original policy |
| C7514 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, with all angioplasty in the central dialysis segment, and transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all required imaging, radiological supervision and interpretation, image documentation and report | New Hampshire Precertification List, Pg 214 Original policy |
| C7515 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, with dialysis circuit permanent endovascular embolization or occlusion of main circuit or any accessory veins, including all required imaging, radiological supervision and interpretation, image documentation and report | New Hampshire Precertification List, Pg 215 Original policy |
| C7517 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, with iliac and/or femoral artery angiograph | New Hampshire Precertification List, Pg 215 Original policy |
| C7530 | Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty and all angioplasty in the central dialysis segment, with transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all imaging, radiological supervision and interpretation, documentation and report | New Hampshire Precertification List, Pg 215 Original policy |
| C7531 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal angioplasty with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation | New Hampshire Precertification List, Pg 215 Original policy |
| C7534 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with atherectomy, includes angioplasty within the same vessel, when performed with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation | New Hampshire Precertification List, Pg 216 Original policy |
| C7535 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal stent placement(s), includes angioplasty within the same vessel, when performed, with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation | New Hampshire Precertification List, Pg 216 Original policy |
| C7538 | Insertion of new or replacement of permanent pacemaker with ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (e.g., for upgrade to dual chamber system) | New Hampshire Precertification List, Pg 216 Original policy |
| C7539 | Insertion of new or replacement of permanent pacemaker with atrial and ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (e.g., for upgrade to dual chamber system) | New Hampshire Precertification List, Pg 216 Original policy |
| C7540 | Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, dual lead system, with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (e.g., for upgrade to dual chamber system) | New Hampshire Precertification List, Pg 216 Original policy |
| C7552 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; wit | New Hampshire Precertification List, Pg 216 Original policy |
| C7553 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; wit | New Hampshire Precertification List, Pg 217 Original policy |
| C8002 | Preparation of skin cell suspension autograft, automated, including all enzymatic processing and device components (do not report with manual suspension preparation) | New Hampshire Precertification List, Pg 217 Original policy |
| C8003 | Implantation of medial knee extraarticular implantable shock absorber spanning the knee joint from distal femur to proximal tibia, open, includes measurements, positioning and adjustments, with imaging guidance (e.g., fluoroscopy) | New Hampshire Precertification List, Pg 217 Original policy |
| C8903 | Magnetic resonance imaging with contrast, breast; unilateral | New Hampshire Precertification List, Pg 217 Original policy |
| C8905 | Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral | New Hampshire Precertification List, Pg 217 Original policy |
| C8906 | Magnetic resonance imaging with contrast, breast; bilateral | New Hampshire Precertification List, Pg 217 Original policy |
| C8908 | Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral | New Hampshire Precertification List, Pg 217 Original policy |
| C9047 | Injection, caplacizumab-yhdp, 1 mg | New Hampshire Precertification List, Pg 217 Original policy |
| C9169 | Injection, nogapendekin alfa inbakicept- pmln, for intravesical use, 1 mcg | New Hampshire Precertification List, Pg 217 Original policy |
| C9170 | Injection, tarlatamab-dlle, 1 mg | New Hampshire Precertification List, Pg 217 Original policy |
| C9172 | Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose | New Hampshire Precertification List, Pg 217 Original policy |
| C9173 | Injection, filgrastim-txid (Nypozi), biosimilar, 1 mcg | New Hampshire Precertification List, Pg 217 Original policy |
| C9257 | Injection, bevacizumab, 0.25 mg | New Hampshire Precertification List, Pg 217 Original policy |
| C9301 | Obecabtagene autoleucel, up to 400 million cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose | New Hampshire Precertification List, Pg 217 Original policy |
| C9302 | Injection, zanidatamab-hrii, 2 mg | New Hampshire Precertification List, Pg 217 Original policy |
| C9303 | Injection, zolbetuximab-clzb, 1 mg | New Hampshire Precertification List, Pg 217 Original policy |
| C9304 | Injection, marstacimab-hncq, 0.5 mg | New Hampshire Precertification List, Pg 217 Original policy |
| C9307 | Injection, linvoseltamab-gcpt, 1 mg | New Hampshire Precertification List, Pg 217 Original policy |
| C9352 | Microporous collagen implantable tube (NeuraGen Nerve Guide), per cm length | New Hampshire Precertification List, Pg 217 Original policy |
| C9353 | Microporous collagen implantable slit tube (NeuraWrap Nerve Protector), per cm length | New Hampshire Precertification List, Pg 217 Original policy |