Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 51
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 |
|---|---|---|
| C9354 | Acellular pericardial tissue matrix of nonhuman origin (Veritas), per sq cm | New Hampshire Precertification List, Pg 217 Original policy |
| C9355 | Collagen nerve cuff (NeuroMatrix), per 0.5 cm length | New Hampshire Precertification List, Pg 218 Original policy |
| C9356 | Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector Sheet), per sq cm | New Hampshire Precertification List, Pg 218 Original policy |
| C9358 | Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm | New Hampshire Precertification List, Pg 218 Original policy |
| C9359 | Porous purified collagen matrix bone void filler (Integra Mozaik Osteoconductive Scaffold Putty, Integra OS Osteoconductive Scaffold Putty), per 0.5 cc | New Hampshire Precertification List, Pg 218 Original policy |
| C9360 | Dermal substitute, native, nondenatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm | New Hampshire Precertification List, Pg 218 Original policy |
| C9361 | Collagen matrix nerve wrap (NeuroMend Collagen Nerve Wrap), per 0.5 cm length | New Hampshire Precertification List, Pg 218 Original policy |
| C9362 | Porous purified collagen matrix bone void filler (Integra Mozaik Osteoconductive Scaffold Strip), per 0.5 cc | New Hampshire Precertification List, Pg 218 Original policy |
| C9363 | Skin substitute (Integra Meshed Bilayer Wound Matrix), per sq cm | New Hampshire Precertification List, Pg 218 Original policy |
| C9364 | Porcine implant, Permacol, per sq cm | New Hampshire Precertification List, Pg 218 Original policy |
| C9399 | Unclassified drugs or biologicals | New Hampshire Precertification List, Pg 218 Original policy |
| C9600 | Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch | New Hampshire Precertification List, Pg 218 Original policy |
| C9601 | Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 218 Original policy |
| C9602 | Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch | New Hampshire Precertification List, Pg 218 Original policy |
| C9603 | Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 219 Original policy |
| C9604 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel | New Hampshire Precertification List, Pg 219 Original policy |
| C9605 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 219 Original policy |
| C9607 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; single vessel | New Hampshire Precertification List, Pg 219 Original policy |
| C9608 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (list separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 219 Original policy |
| C9727 | Insertion of implants into the soft palate; minimum of 3 implants | New Hampshire Precertification List, Pg 219 Original policy |
| C9734 | Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (MR) guidance | New Hampshire Precertification List, Pg 219 Original policy |
| C9751 | Bronchoscopy, rigid or flexible, transbronchial ablation of lesion(s) by microwave energy, including fluoroscopic guidance, when performed, with computed tomography acquisition(s) and 3D rendering, computer-assisted, image- guided navigation, and endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (e.g., aspiration[s]/biopsy[ies]) and all mediastinal and/or hilar lymph node stations or structures and therapeutic intervention(s) | New Hampshire Precertification List, Pg 220 Original policy |
| C9762 | Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging | New Hampshire Precertification List, Pg 220 Original policy |
| C9763 | Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging | New Hampshire Precertification List, Pg 220 Original policy |
| C9764 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed | New Hampshire Precertification List, Pg 220 Original policy |
| C9765 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed | New Hampshire Precertification List, Pg 220 Original policy |
| C9766 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed | New Hampshire Precertification List, Pg 220 Original policy |
| C9767 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed | New Hampshire Precertification List, Pg 220 Original policy |
| C9772 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed | New Hampshire Precertification List, Pg 220 Original policy |
| C9773 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed | New Hampshire Precertification List, Pg 221 Original policy |
| C9774 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed | New Hampshire Precertification List, Pg 221 Original policy |
| C9775 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed | New Hampshire Precertification List, Pg 221 Original policy |
| C9781 | Arthroscopy, shoulder, surgical; with implantation of subacromial spacer (e.g., balloon), includes debridement (e.g., limited or extensive), subacromial decompression, acromioplasty, and biceps tenodesis when performed | New Hampshire Precertification List, Pg 221 Original policy |
| C9784 | Gastric restrictive procedure, endoscopic sleeve gastroplasty, with esophagogastroduodenoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components | New Hampshire Precertification List, Pg 221 Original policy |
| C9785 | Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components | New Hampshire Precertification List, Pg 221 Original policy |
| C9796 | Repair of enterocutaneous fistula small intestine or colon (excluding anorectal fistula) with plug (e.g., porcine small intestine submucosa [SIS]) | New Hampshire Precertification List, Pg 221 Original policy |
| C9797 | Vascular embolization or occlusion procedure with use of a pressure- generating catheter (e.g., one-way valve, intermittently occluding), inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction | New Hampshire Precertification List, Pg 221 Original policy |
| C9807 | Nerve stimulator, percutaneous, peripheral (e.g., sprint peripheral nerve stimulation system), including electrode and all disposable system components, nonopioid medical device (must be a qualifying Medicare nonopioid medical device for postsurgical pain relief in accordance with Section 4135 of the CAA, 2023) | New Hampshire Precertification List, Pg 222 Original policy |
| C9808 | Nerve cryoablation probe (e.g., cryoICE, cryoSPHERE, cryoSPHERE MAX, cryo2), including probe and all disposable system components, nonopioid medical device (must be a qualifying Medicare nonopioid medical device for postsurgical pain relief in accordance with Section 4135 of the CAA, 2023) | New Hampshire Precertification List, Pg 222 Original policy |
| C9809 | Cryoablation needle (e.g., iovera system), including needle/tip and all disposable system components, nonopioid medical device (must be a qualifying Medicare nonopioid medical device for postsurgical pain relief in accordance with Section 4135 of the CAA, 2023) | New Hampshire Precertification List, Pg 222 Original policy |
| D7810 | Open reduction of dislocation | New Hampshire Precertification List, Pg 222 Original policy |
| D7820 | Closed reduction of dislocation | New Hampshire Precertification List, Pg 222 Original policy |
| D7830 | Manipulation under anesthesia | New Hampshire Precertification List, Pg 222 Original policy |
| D7840 | Condylectomy | New Hampshire Precertification List, Pg 222 Original policy |
| D7850 | Surgical discectomy, with/without implant | New Hampshire Precertification List, Pg 222 Original policy |
| D7852 | Disc repair | New Hampshire Precertification List, Pg 222 Original policy |
| D7854 | Synovectomy | New Hampshire Precertification List, Pg 222 Original policy |
| D7856 | Myotomy | New Hampshire Precertification List, Pg 222 Original policy |
| D7858 | Joint reconstruction | New Hampshire Precertification List, Pg 222 Original policy |
| D7860 | Arthrotomy | New Hampshire Precertification List, Pg 222 Original policy |