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Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 70

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
Q4330TOTAL, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4331Axolotl Graft, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4332Axolotl DualGraft, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4333ArdeoGraft, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4334Amnioplast 1, per square centimeterNew Hampshire Precertification List, Pg 262 Original policy
Q4335Amnioplast 2, per square centimeterNew Hampshire Precertification List, Pg 262 Original policy
Q4336Artacent c, per square centimeterNew Hampshire Precertification List, Pg 262 Original policy
Q4337Artacent trident, per square centimeterNew Hampshire Precertification List, Pg 262 Original policy
Q4338Artacent velos, per square centimeterNew Hampshire Precertification List, Pg 262 Original policy
Q4339Artacent vericlen, per square centimeterNew Hampshire Precertification List, Pg 262 Original policy
Q4340Simpligraft, per square centimeterNew Hampshire Precertification List, Pg 262 Original policy
Q4341Simplimax, per square centimeterNew Hampshire Precertification List, Pg 262 Original policy
Q4342Theramend, per square centimeterNew Hampshire Precertification List, Pg 262 Original policy
Q4343Dermacyte ac matrix amniotic membrane allograft, per square centimeterNew Hampshire Precertification List, Pg 262 Original policy
Q4344Tri-membrane wrap, per square centimeterNew Hampshire Precertification List, Pg 262 Original policy
Q4345Matrix hd allograft dermis, per square centimeterNew Hampshire Precertification List, Pg 262 Original policy
Q4346Shelter DM Matrix, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4347Rampart DL Matrix, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4348Sentry SL Matrix, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4349Mantle DL Matrix, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4350Palisade DM Matrix, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4351Enclose TL Matrix, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4352Overlay SL Matrix, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4353Xceed TL Matrix, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4354PalinGen Dual-Layer Membrane, per sq cNew Hampshire Precertification List, Pg 262 Original policy
Q4355Abiomend Xplus Membrane and AbiomenNew Hampshire Precertification List, Pg 262 Original policy
Q4356Abiomend Membrane and Abiomend HydrNew Hampshire Precertification List, Pg 262 Original policy
Q4357XWRAP Plus, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4358XWRAP Dual, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4359ChoriPly, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4360AmchoPlast FD, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4361EPIXPRESS, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4362CYGNUS Disk, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4363Amnio Burgeon Membrane and HydromeNew Hampshire Precertification List, Pg 262 Original policy
Q4364Amnio Burgeon Xplus Membrane and XplNew Hampshire Precertification List, Pg 262 Original policy
Q4365Amnio Burgeon Dual-Layer Membrane, peNew Hampshire Precertification List, Pg 262 Original policy
Q4366Dual Layer Amnio Burgeon X-MembraneNew Hampshire Precertification List, Pg 262 Original policy
Q4367AmnioCore SL, per sq cmNew Hampshire Precertification List, Pg 262 Original policy
Q4369Amnioplast 3, per square centimeter (add- on, list separately in addition to primary procedure)New Hampshire Precertification List, Pg 262 Original policy
Q5098Injection, ustekinumab-srlf (Imuldosa), biosimilNew Hampshire Precertification List, Pg 262 Original policy
Q5099Injection, ustekinumab-stba (Steqeyma), bNew Hampshire Precertification List, Pg 262 Original policy
Q5100Injection, ustekinumab-kfce (Yesintek), bioNew Hampshire Precertification List, Pg 262 Original policy
Q5101Injection, filgrastim-sndz, biosimilar, (Zarxio), 1 mcgNew Hampshire Precertification List, Pg 263 Original policy
Q5103Injection, infliximab-dyyb, biosimilar, (Inflectra), 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5104Injection, infliximab-abda, biosimilar, (Renflexis), 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5105Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for ESRD on dialysis), 100 unitsNew Hampshire Precertification List, Pg 263 Original policy
Q5106Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for non-ESRD use), 1000 unitsNew Hampshire Precertification List, Pg 263 Original policy
Q5107Injection, bevacizumab-awwb, biosimilar, (Mvasi), 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5108Injection, pegfilgrastim-jmdb (Fulphila), biosimilar, 0.5 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5109Injection, infliximab-qbtx, biosimilar, (Ixifi), 10 mgNew Hampshire Precertification List, Pg 263 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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