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Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 65

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
L8678Electrical stimulator supplies (external) for use with implantable neurostimulator, per monthNew Hampshire Precertification List, Pg 252 Original policy
L8679Implantable neurostimulator, pulse generator, any typeNew Hampshire Precertification List, Pg 252 Original policy
L8680Implantable neurostimulator electrode, eachNew Hampshire Precertification List, Pg 252 Original policy
L8681Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement onlyNew Hampshire Precertification List, Pg 252 Original policy
L8682Implantable neurostimulator radiofrequency receiverNew Hampshire Precertification List, Pg 252 Original policy
L8683Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiverNew Hampshire Precertification List, Pg 252 Original policy
L8684Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacementNew Hampshire Precertification List, Pg 252 Original policy
L8685Implantable neurostimulator pulse generator, single array, rechargeable, includes extensionNew Hampshire Precertification List, Pg 252 Original policy
L8686Implantable neurostimulator pulse generator, single array, non- rechargeable, includes extensionNew Hampshire Precertification List, Pg 252 Original policy
L8687Implantable neurostimulator pulse generator, dual array, rechargeable, includes extensionNew Hampshire Precertification List, Pg 252 Original policy
L8688Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extensionNew Hampshire Precertification List, Pg 253 Original policy
L8690Auditory osseointegrated device, includes all internal and external componentsNew Hampshire Precertification List, Pg 253 Original policy
L8691Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, eachNew Hampshire Precertification List, Pg 253 Original policy
L8692Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachmentNew Hampshire Precertification List, Pg 253 Original policy
L8693Auditory osseointegrated device abutment, any length, replacement onlyNew Hampshire Precertification List, Pg 253 Original policy
L8694Auditory osseointegrated device, transducer/actuator, replacement only, eachNew Hampshire Precertification List, Pg 253 Original policy
L8701Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricatedNew Hampshire Precertification List, Pg 253 Original policy
L8702Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricatedNew Hampshire Precertification List, Pg 253 Original policy
Q0138Injection, ferumoxytol, for treatment ofNew Hampshire Precertification List, Pg 253 Original policy
Q2026Injection, Radiesse, 0.1mlNew Hampshire Precertification List, Pg 253 Original policy
Q2028Injection, sculptra, 0.5 mgNew Hampshire Precertification List, Pg 253 Original policy
Q2041Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR positive T cells, including leukapheresis and dose preparation procedures, per therapeutic doseNew Hampshire Precertification List, Pg 253 Original policy
Q2042Tisagenlecleucel, up to 600 million CAR- positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic doseNew Hampshire Precertification List, Pg 253 Original policy
Q2043Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap- gm-csf, including leukapheresis and all other preparatory procedures, per infusionNew Hampshire Precertification List, Pg 253 Original policy
Q2049Injection, doxorubicin HCl, liposomal, imported Lipodox, 10 mgNew Hampshire Precertification List, Pg 253 Original policy
Q2050Injection, doxorubicin HCl, liposomal, not otherwise specified, 10 mgNew Hampshire Precertification List, Pg 254 Original policy
Q2053Brexucabtagene autoleucel, up to 200 million autologous anti-CD19 CAR positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic doseNew Hampshire Precertification List, Pg 254 Original policy
Q2054Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR- positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic doseNew Hampshire Precertification List, Pg 254 Original policy
Q2055Idecabtagene vicleucel, up to 510 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, per therapeutic doseNew Hampshire Precertification List, Pg 254 Original policy
Q2056Ciltacabtagene autoleucel, up to 100 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T cells, including leukapheresis and dose preparation procedures, per therapeutic doseNew Hampshire Precertification List, Pg 254 Original policy
Q2057Afamitresgene autoleucel, including leukapheresis and dose preparation procedures, per therapeutic doseNew Hampshire Precertification List, Pg 254 Original policy
Q2058Obecabtagene autoleucel, 10 up to 400 million CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per infusionNew Hampshire Precertification List, Pg 254 Original policy
Q3001Radioelements for brachytherapy, any type, eachNew Hampshire Precertification List, Pg 254 Original policy
Q3027Injection, interferon beta-1a, 1 mcg for intramuscular useNew Hampshire Precertification List, Pg 254 Original policy
Q3028Injection, interferon beta-1a, 1 mcg for subcutaneous useNew Hampshire Precertification List, Pg 254 Original policy
Q4074Iloprost, inhalation solution, FDA- approved final product, noncompounded, administered through DME, unit dose form, up to 20 mcgNew Hampshire Precertification List, Pg 254 Original policy
Q4081Injection, epoetin alfa, 100 units (for ESRD on dialysis)New Hampshire Precertification List, Pg 254 Original policy
Q4100Skin substitute, not otherwise specifiedNew Hampshire Precertification List, Pg 254 Original policy
Q4101Apligraf, per sq cmNew Hampshire Precertification List, Pg 254 Original policy
Q4102Oasis wound matrix, per sq cmNew Hampshire Precertification List, Pg 254 Original policy
Q4103Oasis burn matrix, per sq cmNew Hampshire Precertification List, Pg 254 Original policy
Q4104Integra bilayer matrix wound dressing (BMWD), per sq cmNew Hampshire Precertification List, Pg 254 Original policy
Q4105Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per sq cmNew Hampshire Precertification List, Pg 254 Original policy
Q4106Dermagraft, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4107GRAFTJACKET, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4108Integra matrix, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4110PriMatrix, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4111GammaGraft, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4112Cymetra, injectable, 1 ccNew Hampshire Precertification List, Pg 255 Original policy
Q4113GRAFTJACKET XPRESS, injectable, 1 ccNew Hampshire Precertification List, Pg 255 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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