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Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 67

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
Q4171Interfyl, 1 mgNew Hampshire Precertification List, Pg 257 Original policy
Q4173PalinGen or PalinGen XPlus, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4174Palingen or promatrx, 0.36 mg per 0.25 ccNew Hampshire Precertification List, Pg 257 Original policy
Q4175Miroderm, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4176Neopatch or Therion, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4177FlowerAmnioFlo, 0.1 ccNew Hampshire Precertification List, Pg 257 Original policy
Q4178FlowerAmnioPatch, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4179FlowerDerm, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4180Revita, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4181Amnio Wound, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4183Surgigraft, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4184Cellesta, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4185Cellesta Flowable Amnion (25 mg per cc); per 0.5 ccNew Hampshire Precertification List, Pg 257 Original policy
Q4186Epifix, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4187Epicord, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4188AmnioArmor, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4189Artacent AC, 1 mgNew Hampshire Precertification List, Pg 257 Original policy
Q4190Artacent AC, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4191Restorigin, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4192Restorigin, 1 ccNew Hampshire Precertification List, Pg 257 Original policy
Q4193Coll-e-Derm, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4194Novachor, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4195PuraPly, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4196PuraPly AM, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4197PuraPly XT, per sq cmNew Hampshire Precertification List, Pg 257 Original policy
Q4198Genesis Amniotic Membrane, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4199Cygnus matrix, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4200SkinTE, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4201Matrion, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4202Keroxx (2.5g/cc), 1ccNew Hampshire Precertification List, Pg 258 Original policy
Q4203Derma-Gide, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4204XWRAP, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4205Membrane Graft or Membrane Wrap, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4206Fluid Flow or Fluid GF, 1 ccNew Hampshire Precertification List, Pg 258 Original policy
Q4208Novafix, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4209SurGraft, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4211Amnion Bio or AxoBioMembrane, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4212AlloGen, per ccNew Hampshire Precertification List, Pg 258 Original policy
Q4213Ascent, 0.5 mgNew Hampshire Precertification List, Pg 258 Original policy
Q4214Cellesta Cord, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4215Axolotl Ambient or Axolotl Cryo, 0.1 mgNew Hampshire Precertification List, Pg 258 Original policy
Q4216Artacent Cord, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4217WoundFix, BioWound, WoundFix Plus, BioWound Plus, WoundFix Xplus or BioWound Xplus, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4218SurgiCORD, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4219SurgiGRAFT-DUAL, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4220BellaCell HD or SureDerm, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4221Amnio Wrap2, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4222ProgenaMatrix, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4224Human Health Factor 10 Amniotic Patch (HHF10-P), per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4225AmnioBind or DermaBind TL, per sq cmNew Hampshire Precertification List, Pg 258 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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