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Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 69

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
Q4280Xcell Amnio Matrix, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4281Barrera SL or Barrera DL, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4282Cygnus Dual, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4283Biovance Tri-Layer or Biovance 3L, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4284DermaBind SL, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4285NuDYN DL or NuDYN DL MESH, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4286NuDYN SL or NuDYN SLW, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4287DermaBind DL, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4288DermaBind CH, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4289RevoShield+ Amniotic Barrier, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4290Membrane Wrap-Hydro, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4291Lamellas XT, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4292Lamellas, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4293Acesso DL, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4294Amnio Quad-Core, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4295Amnio Tri-Core Amniotic, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4296Rebound Matrix, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4297Emerge Matrix, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4298AmniCore Pro, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4299AmniCore Pro+, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4300Acesso TL, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4301Activate Matrix, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4302Complete ACA, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4303Complete AA, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4304GRAFIX PLUS, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4305American Amnion AC Tri-Layer, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4306American Amnion AC, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4307American Amnion, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4308Sanopellis, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4309VIA Matrix, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4310Procenta, per 100 mgNew Hampshire Precertification List, Pg 261 Original policy
Q4311Acesso, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4312Acesso AC, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4313DermaBind FM, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4314Reeva FT, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4315RegeneLink Amniotic Membrane Allograft, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4316AmchoPlast, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4317VitoGraft, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4318E-Graft, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4319SanoGraft, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4320PelloGraft, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4321RenoGraft, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4322CaregraFT, per sq cmNew Hampshire Precertification List, Pg 261 Original policy
Q4323alloPLY, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4324AmnioTX, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4325ACApatch, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4326WoundPlus, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4327DuoAmnion, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4328MOST, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4329Singlay, per sq cmNew Hampshire Precertification List, Pg 262 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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