21154 prior authorization | Anthem Blue Cross and Blue Shield New Hampshire

21154, Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I, is on the Anthem Blue Cross and Blue Shield New Hampshire prior authorization list. Not a coverage or referral decision.

Code: 21154
Description: Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I
Source: New Hampshire Precertification List, Pg 86 Original policy

Anthem Blue Cross and Blue Shield New Hampshire prior authorization

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