Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 72
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
| Code | Description | Source |
|---|---|---|
| S0201 | Partial Hospitalization Services, Less Than 24 Hours, Per Diem | New Hampshire Precertification List, Pg 265 Original policy |
| S1091 | Stent, noncoronary, temporary, with delivery system (Propel) | New Hampshire Precertification List, Pg 265 Original policy |
| S2053 | Transplantation of small intestine and liver allografts | New Hampshire Precertification List, Pg 265 Original policy |
| S2054 | Transplantation of multivisceral organs | New Hampshire Precertification List, Pg 265 Original policy |
| S2055 | Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor | New Hampshire Precertification List, Pg 265 Original policy |
| S2060 | Lobar lung transplantation | New Hampshire Precertification List, Pg 265 Original policy |
| S2061 | Donor lobectomy (lung) for transplantation, living donor | New Hampshire Precertification List, Pg 265 Original policy |
| S2065 | Simultaneous pancreas kidney transplantation | New Hampshire Precertification List, Pg 265 Original policy |
| S2066 | Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral | New Hampshire Precertification List, Pg 265 Original policy |
| S2067 | Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral | New Hampshire Precertification List, Pg 265 Original policy |
| S2068 | Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral | New Hampshire Precertification List, Pg 265 Original policy |
| S2080 | Laser-assisted uvulopalatoplasty (LAUP) | New Hampshire Precertification List, Pg 265 Original policy |
| S2102 | Islet cell tissue transplant from pancreas; allogeneic | New Hampshire Precertification List, Pg 265 Original policy |
| S2103 | Adrenal tissue transplant to brain | New Hampshire Precertification List, Pg 265 Original policy |
| S2112 | Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells) | New Hampshire Precertification List, Pg 265 Original policy |
| S2117 | Arthroereisis, subtalar | New Hampshire Precertification List, Pg 265 Original policy |
| S2118 | Metal-on-metal total hip resurfacing including acetabular and femoral components | New Hampshire Precertification List, Pg 266 Original policy |
| S2120 | Low density lipoprotein (LDL) apheresis using heparin-induced extracorporeal LDL precipitation | New Hampshire Precertification List, Pg 266 Original policy |
| S2140 | Cord blood harvesting for transplantation, allogeneic | New Hampshire Precertification List, Pg 266 Original policy |
| S2142 | Cord blood-derived stem-cell transplantation, allogeneic | New Hampshire Precertification List, Pg 266 Original policy |
| S2150 | Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; marrow ablative therapy; drugs, supplies, hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and posttransplant care in the global definition | New Hampshire Precertification List, Pg 266 Original policy |
| S2202 | Echosclerotherapy | New Hampshire Precertification List, Pg 266 Original policy |
| S2230 | Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear | New Hampshire Precertification List, Pg 266 Original policy |
| S2235 | Implantation of auditory brain stem implant | New Hampshire Precertification List, Pg 266 Original policy |
| S2300 | Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy | New Hampshire Precertification List, Pg 266 Original policy |
| S2340 | Chemodenervation of abductor muscle(s) of vocal cord | New Hampshire Precertification List, Pg 266 Original policy |
| S2341 | Chemodenervation of adductor muscle(s) of vocal cord | New Hampshire Precertification List, Pg 266 Original policy |
| S2342 | Nasal endoscopy for postoperative debridement following functional endoscopic sinus surgery, nasal and/or sinus cavity(s), unilateral or bilateral | New Hampshire Precertification List, Pg 266 Original policy |
| S2348 | Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar | New Hampshire Precertification List, Pg 266 Original policy |
| S3800 | Genetic testing for amyotrophic lateral sclerosis (ALS) | New Hampshire Precertification List, Pg 266 Original policy |
| S3840 | DNA analysis for germline mutations of the RET proto-oncogene for susceptibility to multiple endocrine neoplasia type 2 | New Hampshire Precertification List, Pg 266 Original policy |
| S3841 | Genetic testing for retinoblastoma | New Hampshire Precertification List, Pg 266 Original policy |
| S3842 | Genetic testing for Von Hippel-Lindau disease | New Hampshire Precertification List, Pg 266 Original policy |
| S3844 | DNA analysis of the connexin 26 gene (gjb2) for susceptibility to congenital, profound deafness | New Hampshire Precertification List, Pg 267 Original policy |
| S3845 | Genetic testing for alpha-thalassemia | New Hampshire Precertification List, Pg 267 Original policy |
| S3846 | Genetic testing for hemoglobin E beta- thalassemia | New Hampshire Precertification List, Pg 267 Original policy |
| S3849 | Genetic testing for Niemann-Pick disease | New Hampshire Precertification List, Pg 267 Original policy |
| S3850 | Genetic testing for sickle cell anemia | New Hampshire Precertification List, Pg 267 Original policy |
| S3852 | DNA analysis for apoe epilson 4 allele for susceptibility to Alzheimer's disease | New Hampshire Precertification List, Pg 267 Original policy |
| S3853 | Genetic testing for myotonic muscular dystrophy | New Hampshire Precertification List, Pg 267 Original policy |
| S3854 | Gene expression profiling panel for use in the management of breast cancer treatment | New Hampshire Precertification List, Pg 267 Original policy |
| S3861 | Genetic testing, sodium channel, voltage- gated, type V, alpha subunit (SCN5A) and variants for suspected Brugada Syndrome | New Hampshire Precertification List, Pg 267 Original policy |
| S3865 | Comprehensive gene sequence analysis for hypertrophic cardiomyopathy | New Hampshire Precertification List, Pg 267 Original policy |
| S3866 | Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family | New Hampshire Precertification List, Pg 267 Original policy |
| S3870 | Comparative genomic hybridization (CGH) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability | New Hampshire Precertification List, Pg 267 Original policy |
| S3900 | Surface electromyography (EMG) | New Hampshire Precertification List, Pg 267 Original policy |
| S4011 | In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development | New Hampshire Precertification List, Pg 267 Original policy |
| S4013 | Complete cycle, gamete intrafallopian transfer (GIFT), case rate | New Hampshire Precertification List, Pg 267 Original policy |
| S4014 | Complete cycle, zygote intrafallopian transfer (ZIFT), case rate | New Hampshire Precertification List, Pg 267 Original policy |
| S4015 | Complete in vitro fertilization cycle, not otherwise specified, case rate | New Hampshire Precertification List, Pg 267 Original policy |