Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 52
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 |
|---|---|---|
| D7865 | Arthroplasty | New Hampshire Precertification List, Pg 222 Original policy |
| D7870 | Arthrocentesis | New Hampshire Precertification List, Pg 222 Original policy |
| D7871 | Nonarthroscopic lysis and lavage | New Hampshire Precertification List, Pg 222 Original policy |
| D7873 | Arthroscopy- surgical: lavage and lysis of adhesions | New Hampshire Precertification List, Pg 222 Original policy |
| D7874 | Arthroscopy- surgical: disc repositioning and stabilization | New Hampshire Precertification List, Pg 222 Original policy |
| D7875 | Arthroscopy- surgical: synovectomy | New Hampshire Precertification List, Pg 222 Original policy |
| D7876 | Arthroscopy- surgical: discectomy | New Hampshire Precertification List, Pg 223 Original policy |
| D7877 | Arthroscopy- surgical: debridement | New Hampshire Precertification List, Pg 223 Original policy |
| D7880 | Occlusal orthotic device, by report | New Hampshire Precertification List, Pg 223 Original policy |
| D7899 | Unspecified TMD therapy, by report | New Hampshire Precertification List, Pg 223 Original policy |
| D7940 | Osteoplasty - for orthognathic deformities | New Hampshire Precertification List, Pg 223 Original policy |
| D7941 | Osteotomy - mandibular rami | New Hampshire Precertification List, Pg 223 Original policy |
| D7943 | Osteotomy - mandibular rami with bone graft; includes obtaining the graft | New Hampshire Precertification List, Pg 223 Original policy |
| D7944 | Osteotomy - segmented or subapical | New Hampshire Precertification List, Pg 223 Original policy |
| D7945 | Osteotomy - body of mandible | New Hampshire Precertification List, Pg 223 Original policy |
| D7946 | LeFort I (maxilla - total) | New Hampshire Precertification List, Pg 223 Original policy |
| D7947 | Lefort I (maxilla - segmented) | New Hampshire Precertification List, Pg 223 Original policy |
| D7948 | LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft | New Hampshire Precertification List, Pg 223 Original policy |
| D7949 | LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - with bone graft | New Hampshire Precertification List, Pg 223 Original policy |
| D7950 | Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report | New Hampshire Precertification List, Pg 223 Original policy |
| D7995 | Synthetic graft - mandible or facial bones, by report | New Hampshire Precertification List, Pg 223 Original policy |
| D7996 | Implant - mandible for augmentation purposes (excluding alveolar ridge), by report | New Hampshire Precertification List, Pg 223 Original policy |
| D9222 | Deep sedation/general anesthesia - first 15 minutes | New Hampshire Precertification List, Pg 223 Original policy |
| D9223 | Deep sedation/general anesthesia - each 15 minute increments | New Hampshire Precertification List, Pg 223 Original policy |
| D9950 | Occlusion analysis- mounted case | New Hampshire Precertification List, Pg 223 Original policy |
| D9951 | Occlusal adjustment- limited | New Hampshire Precertification List, Pg 223 Original policy |
| D9952 | Occlusal adjustment- complete | New Hampshire Precertification List, Pg 223 Original policy |
| E0217 | Water circulating heat pad with pump | New Hampshire Precertification List, Pg 223 Original policy |
| E0218 | Fluid circulating cold pad with pump, any type | New Hampshire Precertification List, Pg 223 Original policy |
| E0236 | Pump for water circulating pad | New Hampshire Precertification List, Pg 223 Original policy |
| E0469 | Lung expansion airway clearance, continuous high frequency oscillation, and nebulization device | New Hampshire Precertification List, Pg 223 Original policy |
| E0470 | Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) | New Hampshire Precertification List, Pg 224 Original policy |
| E0471 | Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) | New Hampshire Precertification List, Pg 224 Original policy |
| E0481 | Intrapulmonary percussive ventilation system and related accessories | New Hampshire Precertification List, Pg 224 Original policy |
| E0485 | Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment | New Hampshire Precertification List, Pg 224 Original policy |
| E0486 | Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment | New Hampshire Precertification List, Pg 224 Original policy |
| E0490 | Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, controlled by hardware remote | New Hampshire Precertification List, Pg 224 Original policy |
| E0491 | Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by hardware remote, 90-day supply | New Hampshire Precertification List, Pg 224 Original policy |
| E0492 | Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, controlled by phone application | New Hampshire Precertification List, Pg 224 Original policy |
| E0493 | Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by phone application, 90-day supply | New Hampshire Precertification List, Pg 224 Original policy |
| E0530 | Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any type | New Hampshire Precertification List, Pg 224 Original policy |
| E0561 | Humidifier, non-heated, used with positive airway pressure device | New Hampshire Precertification List, Pg 224 Original policy |
| E0562 | Humidifier, heated, used with positive airway pressure device | New Hampshire Precertification List, Pg 224 Original policy |
| E0601 | Continuous positive airway pressure (CPAP) device | New Hampshire Precertification List, Pg 224 Original policy |
| E0616 | Implantable cardiac event recorder with memory, activator, and programmer | New Hampshire Precertification List, Pg 225 Original policy |
| E0650 | Pneumatic compressor, nonsegmental home model | New Hampshire Precertification List, Pg 225 Original policy |
| E0651 | Pneumatic compressor, segmental home model without calibrated gradient pressure | New Hampshire Precertification List, Pg 225 Original policy |
| E0652 | Pneumatic compressor, segmental home model with calibrated gradient pressure | New Hampshire Precertification List, Pg 225 Original policy |
| E0655 | Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm | New Hampshire Precertification List, Pg 225 Original policy |
| E0656 | Segmental pneumatic appliance for use with pneumatic compressor, trunk | New Hampshire Precertification List, Pg 225 Original policy |