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

Filter By:
Clear Filters
12465 Results

Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)

Service Code
29914 (CPT) Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)

Service Code
29915 (CPT) Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Arthroscopy, hip, surgical; with labral repair

Service Code
29916 (CPT) Arthroscopy, hip, surgical; with labral repair
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Unlisted procedure, arthroscopy

Service Code
29999 (CPT) Unlisted procedure, arthroscopy
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Drainage abscess or hematoma, nasal, internal approach

Service Code
30000 (CPT) Drainage abscess or hematoma, nasal, internal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Drainage abscess or hematoma, nasal septum

Service Code
30020 (CPT) Drainage abscess or hematoma, nasal septum
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Biopsy, intranasal

Service Code
30100 (CPT) Biopsy, intranasal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, nasal polyp(s), simple

Service Code
30110 (CPT) Excision, nasal polyp(s), simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, nasal polyp(s), extensive

Service Code
30115 (CPT) Excision, nasal polyp(s), extensive
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision or destruction (eg, laser), intranasal lesion; internal approach

Service Code
30117 (CPT) Excision or destruction (eg, laser), intranasal lesion; internal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision or destruction (eg, laser), intranasal lesion; external approach (lateral rhinotomy)

Service Code
30118 (CPT) Excision or destruction (eg, laser), intranasal lesion; external approach (lateral rhinotomy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision or surgical planing of skin of nose for rhinophyma

Service Code
30120 (CPT) Excision or surgical planing of skin of nose for rhinophyma
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Excision dermoid cyst, nose; simple, skin, subcutaneous

Service Code
30124 (CPT) Excision dermoid cyst, nose; simple, skin, subcutaneous
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision dermoid cyst, nose; complex, under bone or cartilage

Service Code
30125 (CPT) Excision dermoid cyst, nose; complex, under bone or cartilage
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision inferior turbinate, partial or complete, any method

Service Code
30130 (CPT) Excision inferior turbinate, partial or complete, any method
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Submucous resection inferior turbinate, partial or complete, any method

Service Code
30140 (CPT) Submucous resection inferior turbinate, partial or complete, any method
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Rhinectomy; partial

Service Code
30150 (CPT) Rhinectomy; partial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Rhinectomy; total

Service Code
30160 (CPT) Rhinectomy; total
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Injection into turbinate(s), therapeutic

Service Code
30200 (CPT) Injection into turbinate(s), therapeutic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Displacement therapy (Proetz type)

Service Code
30210 (CPT) Displacement therapy (Proetz type)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required