21147 prior authorization | Anthem Blue Cross and Blue Shield New Hampshire

21147, Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies), is on the Anthem Blue Cross and Blue Shield New Hampshire prior authorization list. Not a coverage or referral decision.

Code: 21147
Description: Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies)
Source: New Hampshire Precertification List, Pg 86 Original policy

Anthem Blue Cross and Blue Shield New Hampshire prior authorization

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