Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 54
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 |
|---|---|---|
| E1801 | Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories | New Hampshire Precertification List, Pg 227 Original policy |
| E1806 | Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories | New Hampshire Precertification List, Pg 227 Original policy |
| E1811 | Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories | New Hampshire Precertification List, Pg 227 Original policy |
| E1816 | Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories | New Hampshire Precertification List, Pg 227 Original policy |
| E1818 | Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories | New Hampshire Precertification List, Pg 228 Original policy |
| E1821 | Replacement soft interface material/cuffs for bi-directional static progressive stretch device | New Hampshire Precertification List, Pg 228 Original policy |
| E1831 | Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories | New Hampshire Precertification List, Pg 228 Original policy |
| E1832 | Static progressive stretch finger device, e | New Hampshire Precertification List, Pg 228 Original policy |
| E1841 | Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories | New Hampshire Precertification List, Pg 228 Original policy |
| E1905 | Virtual reality cognitive behavioral therapy device (cbt), including pre- programmed therapy software | New Hampshire Precertification List, Pg 228 Original policy |
| E2298 | Complex rehabilitative power wheelchair accessory, power seat elevation system, any type | New Hampshire Precertification List, Pg 228 Original policy |
| G0176 | Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more) | New Hampshire Precertification List, Pg 228 Original policy |
| G0255 | Current perception threshold/sensory nerve conduction test, (SNCT) per limb, any nerve | New Hampshire Precertification List, Pg 228 Original policy |
| G0260 | Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography | New Hampshire Precertification List, Pg 228 Original policy |
| G0277 | Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval | New Hampshire Precertification List, Pg 228 Original policy |
| G0281 | Electrical stimulation, (unattended), to one or more areas, for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care | New Hampshire Precertification List, Pg 228 Original policy |
| G0282 | Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281 | New Hampshire Precertification List, Pg 228 Original policy |
| G0283 | Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care | New Hampshire Precertification List, Pg 228 Original policy |
| G0289 | Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee | New Hampshire Precertification List, Pg 229 Original policy |
| G0295 | Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses | New Hampshire Precertification List, Pg 229 Original policy |
| G0329 | Electromagnetic therapy, to one or more areas for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care | New Hampshire Precertification List, Pg 229 Original policy |
| G0330 | Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating room | New Hampshire Precertification List, Pg 229 Original policy |
| G0339 | Image guided robotic linear accelerator- based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment | New Hampshire Precertification List, Pg 229 Original policy |
| G0340 | Image guided robotic linear accelerator- based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment | New Hampshire Precertification List, Pg 229 Original policy |
| G0341 | Percutaneous islet cell transplant, includes portal vein catheterization and infusion | New Hampshire Precertification List, Pg 229 Original policy |
| G0342 | Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion | New Hampshire Precertification List, Pg 229 Original policy |
| G0343 | Laparotomy for islet cell transplant, includes portal vein catheterization and infusion | New Hampshire Precertification List, Pg 229 Original policy |
| G0398 | Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation | New Hampshire Precertification List, Pg 229 Original policy |
| G0399 | Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation | New Hampshire Precertification List, Pg 229 Original policy |
| G0400 | Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels | New Hampshire Precertification List, Pg 230 Original policy |
| G0428 | Collagen meniscus implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex) | New Hampshire Precertification List, Pg 230 Original policy |
| G0429 | Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy) | New Hampshire Precertification List, Pg 230 Original policy |
| G0448 | Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac venous system, for left ventricular pacing | New Hampshire Precertification List, Pg 230 Original policy |
| G0458 | Low dose rate (ldr) prostate brachytherapy services, composite rate | New Hampshire Precertification List, Pg 230 Original policy |
| G0460 | Autologous platelet rich plasma (PRP) or other blood-derived product for nondiabetic chronic wounds/ulcers (includes, as applicable: administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment) | New Hampshire Precertification List, Pg 230 Original policy |
| G0465 | Autologous platelet rich plasma (PRP) or other blood-derived product for diabetic chronic wounds/ulcers, using an FDA- cleared device for this indication, (includes, as applicable: administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment) | New Hampshire Precertification List, Pg 230 Original policy |
| G2082 | Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self administration, includes 2 hours post administration observation | New Hampshire Precertification List, Pg 230 Original policy |
| G2083 | Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg esketamine nasal self administration, includes 2 hours post administration observation | New Hampshire Precertification List, Pg 230 Original policy |
| G6001 | Ultrasonic guidance for placement of radiation therapy fields | New Hampshire Precertification List, Pg 230 Original policy |
| G6002 | Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy | New Hampshire Precertification List, Pg 231 Original policy |
| G6003 | Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to 5 mev | New Hampshire Precertification List, Pg 231 Original policy |
| G6004 | Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 6-10 mev | New Hampshire Precertification List, Pg 231 Original policy |
| G6005 | Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 11-19 mev | New Hampshire Precertification List, Pg 231 Original policy |
| G6006 | Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 20 mev or greater | New Hampshire Precertification List, Pg 231 Original policy |
| G6007 | Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks: up to 5 mev | New Hampshire Precertification List, Pg 231 Original policy |
| G6008 | Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks: 6-10 mev | New Hampshire Precertification List, Pg 231 Original policy |
| G6009 | Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks: 11-19 mev | New Hampshire Precertification List, Pg 231 Original policy |
| G6010 | Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks: 20 mev or greater | New Hampshire Precertification List, Pg 231 Original policy |
| G6011 | Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 mev | New Hampshire Precertification List, Pg 231 Original policy |
| G6012 | Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 mev | New Hampshire Precertification List, Pg 231 Original policy |