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Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 73

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
S4016Frozen in vitro fertilization cycle, case rateNew Hampshire Precertification List, Pg 267 Original policy
S4017Incomplete cycle, treatment cancelled prior to stimulation, case rateNew Hampshire Precertification List, Pg 267 Original policy
S4018Frozen embryo transfer procedure cancelled before transfer, case rateNew Hampshire Precertification List, Pg 267 Original policy
S4020In vitro fertilization procedure cancelled before aspiration, case rateNew Hampshire Precertification List, Pg 268 Original policy
S4021In vitro fertilization procedure cancelled after aspiration, case rateNew Hampshire Precertification List, Pg 268 Original policy
S4022Assisted oocyte fertilization, case rateNew Hampshire Precertification List, Pg 268 Original policy
S4023Donor egg cycle, incomplete, case rateNew Hampshire Precertification List, Pg 268 Original policy
S4025Donor services for in vitro fertilization (sperm or embryo), case rateNew Hampshire Precertification List, Pg 268 Original policy
S4026Procurement of donor sperm from sperm bankNew Hampshire Precertification List, Pg 268 Original policy
S4027Storage of previously frozen embryosNew Hampshire Precertification List, Pg 268 Original policy
S4028Microsurgical epididymal sperm aspiration (MESA)New Hampshire Precertification List, Pg 268 Original policy
S4030Sperm procurement and cryopreservation services; initial visitNew Hampshire Precertification List, Pg 268 Original policy
S4031Sperm procurement and cryopreservation services; subsequent visitNew Hampshire Precertification List, Pg 268 Original policy
S4035Stimulated intrauterine insemination (IUI), case rateNew Hampshire Precertification List, Pg 268 Original policy
S4037Cryopreserved embryo transfer, case rateNew Hampshire Precertification List, Pg 268 Original policy
S4040Monitoring and storage of cryopreserved embryos, per 30 daysNew Hampshire Precertification List, Pg 268 Original policy
S8030Scleral application of tantalum ring(s) for localization of lesions for proton beam therapyNew Hampshire Precertification List, Pg 268 Original policy
S8035Magnetic source imagingNew Hampshire Precertification List, Pg 268 Original policy
S8037Magnetic resonance cholangiopancreatography (MRCP)New Hampshire Precertification List, Pg 268 Original policy
S8040Topographic brain mappingNew Hampshire Precertification List, Pg 268 Original policy
S8130Interferential current stimulator, 2 channelNew Hampshire Precertification List, Pg 268 Original policy
S8131Interferential current stimulator, 4 channelNew Hampshire Precertification List, Pg 268 Original policy
S8930Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with patientNew Hampshire Precertification List, Pg 268 Original policy
S8940Equestrian/hippotherapy, per sessionNew Hampshire Precertification List, Pg 268 Original policy
S8948Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutesNew Hampshire Precertification List, Pg 268 Original policy
S8950Complex lymphedema therapy, each 15 minutesNew Hampshire Precertification List, Pg 268 Original policy
S8990Physical or manipulative therapy performed for maintenance rather than restorationNew Hampshire Precertification List, Pg 268 Original policy
S9002Intravaginal motion sensor system, provides biofeedback for pelvic floor muscle rehabilitation deviceNew Hampshire Precertification List, Pg 268 Original policy
S9056Coma stimulation per diemNew Hampshire Precertification List, Pg 269 Original policy
S9090Vertebral axial decompression, per sessionNew Hampshire Precertification List, Pg 269 Original policy
S9123Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used)New Hampshire Precertification List, Pg 269 Original policy
S9124Nursing care, in the home; by licensed practical nurse, per hourNew Hampshire Precertification List, Pg 269 Original policy
S9152Speech therapy, re-evaluationNew Hampshire Precertification List, Pg 269 Original policy
S9347Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or subcutaneous infusion therapy (e.g., epoprostenol); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 269 Original policy
S9359Home infusion therapy, antitumor necrosis factor intravenous therapy; (e.g., Infliximab); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 269 Original policy
S9364Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem (do not use with home infusion codes S9365-S9368 using daily volume scales)New Hampshire Precertification List, Pg 269 Original policy
S9365Home infusion therapy, total parenteral nutrition (TPN); one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 269 Original policy
S9366Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 270 Original policy
S9367Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 270 Original policy
S9368Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 270 Original policy
S9480Intensive outpatient psychiatric services, per diemNew Hampshire Precertification List, Pg 270 Original policy
S9494Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code with home infusion codes for hourly dosing schedules S9497-S9504)New Hampshire Precertification List, Pg 270 Original policy
S9497Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 3 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 270 Original policy
S9500Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 271 Original policy
S9501Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 271 Original policy
S9502Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 271 Original policy
S9503Home infusion therapy, antibiotic, antiviral, or antifungal; once every 6 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 271 Original policy
S9504Home infusion therapy, antibiotic, antiviral, or antifungal; once every 4 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 271 Original policy
S9558Home injectable therapy; growth hormone, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 271 Original policy
S9559Home injectable therapy, interferon, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diemNew Hampshire Precertification List, Pg 271 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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