PA Lookup

If you have questions about prior authorizations, please call:

Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12465 Results

Application of short leg cast (below knee to toes);

Service Code
29405 (CPT) Application of short leg cast (below knee to toes);
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

Prior approval (PA) is required prior to the start of all treatment services. The provider shall submit a request to the DHHS utilization review contractor to start the PA process. Detailed information and instructions for registering and submitting requests is available on the DHHS utilization review contractor's website: https://choicepa.medicaidprograms.org/Account/Login.aspx?ReturnUrl=%2f The PA request must clearly indicate that the service of a licensed therapist is required. For a beneficiary under age 21, the provider shall submit information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available. A written evaluation report must be completed within three months of the requested treatment start date. When continued treatment is requested, an annual re-evaluation of the beneficiary’s status and performance must be documented in a written evaluation report. Each reauthorization request must document the efficacy of treatment. When granted, the approval is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. Retroactive PA is considered when Medicaid coverage is granted with a retroactive eligibility date after a beneficiary receives a service. Medicaid does not guarantee approval of retroactive PA requests.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Application of short leg cast (below knee to toes);

Service Code
29405 (CPT) Application of short leg cast (below knee to toes);
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Physical Health

Authorization Guidelines

The prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Application of short leg cast (below knee to toes); walking or ambulatory type

Service Code
29425 (CPT) Application of short leg cast (below knee to toes); walking or ambulatory type
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

Prior approval (PA) is required prior to the start of all treatment services. The provider shall submit a request to the DHHS utilization review contractor to start the PA process. Detailed information and instructions for registering and submitting requests is available on the DHHS utilization review contractor's website: https://choicepa.medicaidprograms.org/Account/Login.aspx?ReturnUrl=%2f The PA request must clearly indicate that the service of a licensed therapist is required. For a beneficiary under age 21, the provider shall submit information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available. A written evaluation report must be completed within three months of the requested treatment start date. When continued treatment is requested, an annual re-evaluation of the beneficiary’s status and performance must be documented in a written evaluation report. Each reauthorization request must document the efficacy of treatment. When granted, the approval is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. Retroactive PA is considered when Medicaid coverage is granted with a retroactive eligibility date after a beneficiary receives a service. Medicaid does not guarantee approval of retroactive PA requests.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Application of patellar tendon bearing (PTB) cast

Service Code
29435 (CPT) Application of patellar tendon bearing (PTB) cast
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Adding walker to previously applied cast

Service Code
29440 (CPT) Adding walker to previously applied cast
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Application of rigid total contact leg cast

Service Code
29445 (CPT) Application of rigid total contact leg cast
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Application of clubfoot cast with molding or manipulation, long or short leg

Service Code
29450 (CPT) Application of clubfoot cast with molding or manipulation, long or short leg
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Application of long leg splint (thigh to ankle or toes)

Service Code
29505 (CPT) Application of long leg splint (thigh to ankle or toes)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

Prior approval (PA) is required prior to the start of all treatment services. The provider shall submit a request to the DHHS utilization review contractor to start the PA process. Detailed information and instructions for registering and submitting requests is available on the DHHS utilization review contractor's website: https://choicepa.medicaidprograms.org/Account/Login.aspx?ReturnUrl=%2f The PA request must clearly indicate that the service of a licensed therapist is required. For a beneficiary under age 21, the provider shall submit information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available. A written evaluation report must be completed within three months of the requested treatment start date. When continued treatment is requested, an annual re-evaluation of the beneficiary’s status and performance must be documented in a written evaluation report. Each reauthorization request must document the efficacy of treatment. When granted, the approval is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. Retroactive PA is considered when Medicaid coverage is granted with a retroactive eligibility date after a beneficiary receives a service. Medicaid does not guarantee approval of retroactive PA requests.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Application of long leg splint (thigh to ankle or toes)

Service Code
29505 (CPT) Application of long leg splint (thigh to ankle or toes)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Physical Health

Authorization Guidelines

The prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Application of short leg splint (calf to foot)

Service Code
29515 (CPT) Application of short leg splint (calf to foot)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

Prior approval (PA) is required prior to the start of all treatment services. The provider shall submit a request to the DHHS utilization review contractor to start the PA process. Detailed information and instructions for registering and submitting requests is available on the DHHS utilization review contractor's website: https://choicepa.medicaidprograms.org/Account/Login.aspx?ReturnUrl=%2f The PA request must clearly indicate that the service of a licensed therapist is required. For a beneficiary under age 21, the provider shall submit information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available. A written evaluation report must be completed within three months of the requested treatment start date. When continued treatment is requested, an annual re-evaluation of the beneficiary’s status and performance must be documented in a written evaluation report. Each reauthorization request must document the efficacy of treatment. When granted, the approval is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. Retroactive PA is considered when Medicaid coverage is granted with a retroactive eligibility date after a beneficiary receives a service. Medicaid does not guarantee approval of retroactive PA requests.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Application of short leg splint (calf to foot)

Service Code
29515 (CPT) Application of short leg splint (calf to foot)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Physical Health

Authorization Guidelines

The prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Strapping; hip

Service Code
29520 (CPT) Strapping; hip
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Strapping; knee

Service Code
29530 (CPT) Strapping; knee
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

Prior approval (PA) is required prior to the start of all treatment services. The provider shall submit a request to the DHHS utilization review contractor to start the PA process. Detailed information and instructions for registering and submitting requests is available on the DHHS utilization review contractor's website: https://choicepa.medicaidprograms.org/Account/Login.aspx?ReturnUrl=%2f The PA request must clearly indicate that the service of a licensed therapist is required. For a beneficiary under age 21, the provider shall submit information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available. A written evaluation report must be completed within three months of the requested treatment start date. When continued treatment is requested, an annual re-evaluation of the beneficiary’s status and performance must be documented in a written evaluation report. Each reauthorization request must document the efficacy of treatment. When granted, the approval is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. Retroactive PA is considered when Medicaid coverage is granted with a retroactive eligibility date after a beneficiary receives a service. Medicaid does not guarantee approval of retroactive PA requests.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Strapping; knee

Service Code
29530 (CPT) Strapping; knee
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Physical Health

Authorization Guidelines

The prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Strapping; ankle and/or foot

Service Code
29540 (CPT) Strapping; ankle and/or foot
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

Prior approval (PA) is required prior to the start of all treatment services. The provider shall submit a request to the DHHS utilization review contractor to start the PA process. Detailed information and instructions for registering and submitting requests is available on the DHHS utilization review contractor's website: https://choicepa.medicaidprograms.org/Account/Login.aspx?ReturnUrl=%2f The PA request must clearly indicate that the service of a licensed therapist is required. For a beneficiary under age 21, the provider shall submit information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available. A written evaluation report must be completed within three months of the requested treatment start date. When continued treatment is requested, an annual re-evaluation of the beneficiary’s status and performance must be documented in a written evaluation report. Each reauthorization request must document the efficacy of treatment. When granted, the approval is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. Retroactive PA is considered when Medicaid coverage is granted with a retroactive eligibility date after a beneficiary receives a service. Medicaid does not guarantee approval of retroactive PA requests.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Strapping; ankle and/or foot

Service Code
29540 (CPT) Strapping; ankle and/or foot
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Physical Health

Authorization Guidelines

The prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Strapping; toes

Service Code
29550 (CPT) Strapping; toes
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Strapping; Unna boot

Service Code
29580 (CPT) Strapping; Unna boot
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Application of multi-layer compression system; leg (below knee), including ankle and foot

Service Code
29581 (CPT) Application of multi-layer compression system; leg (below knee), including ankle and foot
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Application of multi-layer compression system; upper arm, forearm, hand, and fingers

Service Code
29584 (CPT) Application of multi-layer compression system; upper arm, forearm, hand, and fingers
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.