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Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 58

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

Prior authorization codes
CodeDescriptionSource
J1599Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mgNew Hampshire Precertification List, Pg 238 Original policy
J1602Injection, golimumab, 1 mg, for intravenous useNew Hampshire Precertification List, Pg 238 Original policy
J1628Injection, guselkumab, 1 mgNew Hampshire Precertification List, Pg 238 Original policy
J1632Injection, brexanolone, 1 mgNew Hampshire Precertification List, Pg 238 Original policy
J1675Injection, histrelin acetate, 10 mcgNew Hampshire Precertification List, Pg 238 Original policy
J1729Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mgNew Hampshire Precertification List, Pg 238 Original policy
J1743Injection, idursulfase, 1 mgNew Hampshire Precertification List, Pg 238 Original policy
J1744Injection, icatibant, 1 mgNew Hampshire Precertification List, Pg 238 Original policy
J1745Injection, infliximab, excludes biosimilar, 10 mgNew Hampshire Precertification List, Pg 238 Original policy
J1746Injection, ibalizumab-uiyk, 10 mgNew Hampshire Precertification List, Pg 238 Original policy
J1747Injection, spesolimab-sbzo, 1 mgNew Hampshire Precertification List, Pg 238 Original policy
J1748Injection, infliximab-dyyb (Zymfentra), 10 mgNew Hampshire Precertification List, Pg 238 Original policy
J1750Injection, iron dextran, 50 mgNew Hampshire Precertification List, Pg 238 Original policy
J1756Injection, iron sucrose, 1 mgNew Hampshire Precertification List, Pg 238 Original policy
J1786Injection, imiglucerase, 10 unitsNew Hampshire Precertification List, Pg 238 Original policy
J1823Injection, inebilizumab-cdon, 1 mgNew Hampshire Precertification List, Pg 238 Original policy
J1826Injection, interferon beta-1a, 30 mcgNew Hampshire Precertification List, Pg 238 Original policy
J1830Injection interferon beta-1b, 0.25 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 238 Original policy
J1930Injection, lanreotide, 1 mgNew Hampshire Precertification List, Pg 238 Original policy
J1931Injection, laronidase, 0.1 mgNew Hampshire Precertification List, Pg 238 Original policy
J1932Injection, lanreotide, (cipla), 1 mgNew Hampshire Precertification List, Pg 238 Original policy
J1951Injection, leuprolide acetate for depot suspension (Fensolvi), 0.25 mgNew Hampshire Precertification List, Pg 238 Original policy
J1954Injection, leuprolide acetate for depot suspension (cipla), 7.5 mgNew Hampshire Precertification List, Pg 238 Original policy
J1956Injection, levofloxacin, 250 mgNew Hampshire Precertification List, Pg 238 Original policy
J1961Injection, lenacapavir, 1 mgNew Hampshire Precertification List, Pg 238 Original policy
J2170Injection, mecasermin, 1 mgNew Hampshire Precertification List, Pg 238 Original policy
J2182Injection, mepolizumab, 1 mgNew Hampshire Precertification List, Pg 238 Original policy
J2183Injection, meropenem (WG Critical Care), not therapeutically equivalent to J2185, 100 mgNew Hampshire Precertification List, Pg 238 Original policy
J2184Injection, meropenem (B. Braun), not therapeutically equivalent to J2185, 100 mgNew Hampshire Precertification List, Pg 239 Original policy
J2185Injection, meropenem, 100 mgNew Hampshire Precertification List, Pg 239 Original policy
J2267Injection, mirikizumab-mrkz, 1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2277Injection, motixafortide, 0.25 mgNew Hampshire Precertification List, Pg 239 Original policy
J2278Injection, ziconotide, 1 mcgNew Hampshire Precertification List, Pg 239 Original policy
J2280Injection, moxifloxacin, 100 mgNew Hampshire Precertification List, Pg 239 Original policy
J2281Injection, moxifloxacin (Fresenius Kabi), not therapeutically equivalent to J2280, 100 mgNew Hampshire Precertification List, Pg 239 Original policy
J2323Imjection, natalizumab, 1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2326Injection, nusinersen, 0.1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2327Injection, risankizumab-rzaa, intravenous, 1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2329Injection, ublituximab-xiiy, 1mgNew Hampshire Precertification List, Pg 239 Original policy
J2350Injection, ocrelizumab, 1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2351Injection, ocrelizumab, 1 mg and hyaluronidase-ocsqNew Hampshire Precertification List, Pg 239 Original policy
J2353Injection, octreotide, depot form for intramuscular injection, 1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2354Injection, octreotide, nondepot form for subcutaneous or intravenous injection, 25 mcgNew Hampshire Precertification List, Pg 239 Original policy
J2356Injection, tezepelumab-ekko, 1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2357Injection, omalizumab, 5 mgNew Hampshire Precertification List, Pg 239 Original policy
J2502Injection, pasireotide long acting, 1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2506Injection, pegfilgrastim, excludes biosimilar, 0.5 mgNew Hampshire Precertification List, Pg 239 Original policy
J2507Injection, pegloticase, 1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2508Injection, pegunigalsidase alfa-iwxj, 1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2510Injection, penicillin G procaine, aqueous, up to 600,000 unitsNew Hampshire Precertification List, Pg 239 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.

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