Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 55
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 |
|---|---|---|
| G6013 | Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 mev | New Hampshire Precertification List, Pg 231 Original policy |
| G6014 | Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 mev or greater | New Hampshire Precertification List, Pg 232 Original policy |
| G6015 | Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session | New Hampshire Precertification List, Pg 232 Original policy |
| G6016 | Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session | New Hampshire Precertification List, Pg 232 Original policy |
| G6017 | Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment | New Hampshire Precertification List, Pg 232 Original policy |
| G9143 | Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s) | New Hampshire Precertification List, Pg 232 Original policy |
| G9147 | Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration | New Hampshire Precertification List, Pg 232 Original policy |
| G9840 | RAS (KRAS and NRAS) gene mutation testing performed before initiation of anti- EGFR MoAb | New Hampshire Precertification List, Pg 232 Original policy |
| G9841 | RAS (KRAS and NRAS) gene mutation testing not performed before initiation of anti-EGFR MoAb | New Hampshire Precertification List, Pg 232 Original policy |
| H0004 | Behavioral health counseling and therapy, per 15 minutes | New Hampshire Precertification List, Pg 232 Original policy |
| H0006 | Alcohol and/or drug services; case management | New Hampshire Precertification List, Pg 232 Original policy |
| H0015 | Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education | New Hampshire Precertification List, Pg 232 Original policy |
| H0017 | Behavioral health; residential (hospital residential treatment program), without room and board, per diem | New Hampshire Precertification List, Pg 233 Original policy |
| H0019 | Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem | New Hampshire Precertification List, Pg 233 Original policy |
| H0023 | Behavioral health outreach service (planned approach to reach a targeted population) | New Hampshire Precertification List, Pg 233 Original policy |
| H0035 | Mental health partial hospitalization, treatment, less than 24 hours | New Hampshire Precertification List, Pg 233 Original policy |
| H0038 | Self-help/peer services, per 15 minutes | New Hampshire Precertification List, Pg 233 Original policy |
| H0039 | Assertive community treatment, face-to- face, per 15 minutes | New Hampshire Precertification List, Pg 233 Original policy |
| H0040 | Assertive community treatment program, per diem | New Hampshire Precertification List, Pg 233 Original policy |
| H2014 | Skills training and development, per 15 minutes | New Hampshire Precertification List, Pg 233 Original policy |
| H2019 | Therapeutic behavioral services, per 15 minutes | New Hampshire Precertification List, Pg 233 Original policy |
| H2020 | Therapeutic behavioral services, per diem | New Hampshire Precertification List, Pg 233 Original policy |
| H2021 | Community-based wrap-around services, per 15 minutes | New Hampshire Precertification List, Pg 234 Original policy |
| J0013 | Esketamine, nasal spray, 1 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0129 | Injection, abatacept, 10 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) | New Hampshire Precertification List, Pg 234 Original policy |
| J0135 | Injection, adalimumab, 20 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0139 | Injection, adalimumab, 1 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0172 | Injection, aducanumab-avwa, 2 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0174 | Injection, lecanemab-irmb, 1 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0175 | Injection, donanemab-azbt, 2 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0177 | Injection, aflibercept HD, 1 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0178 | Injection, aflibercept, 1 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0179 | Injection, brolucizumab-dbll, 1 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0180 | Injection, agalsidase beta, 1 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0202 | Injection, alemtuzumab, 1 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0207 | Injection, amifostine, 500 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0208 | Injection, sodium thiosulfate (Pedmark), 100 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0217 | Injection, velmanase alfa-tycv, 1 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0218 | Injection, olipudase alfa-rpcp, 1 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0219 | Injection, avalglucosidase alfa-ngpt, 4 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0221 | Injection, alglucosidase alfa, (Lumizyme), 10 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0222 | Injection, patisiran, 0.1 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0223 | Injection, givosiran, 0.5 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0224 | Injection, lumasiran, 0.5 m | New Hampshire Precertification List, Pg 234 Original policy |
| J0225 | Injection, vutrisiran, 1 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0256 | Injection, alpha 1-proteinase inhibitor (human), not otherwise specified, 10 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0257 | Injection, alpha 1 proteinase inhibitor (human), (GLASSIA), 10 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0456 | Injection, azithromycin, 500 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0485 | Injection, belatacept, 1 mg | New Hampshire Precertification List, Pg 234 Original policy |
| J0490 | Injection, belimumab, 10 mg | New Hampshire Precertification List, Pg 234 Original policy |