PA Lookup

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

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

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12465 Results

Removal of intra-aortic balloon assist device including repair of femoral artery, with or without graft

Service Code
33971 (CPT) Removal of intra-aortic balloon assist device including repair of femoral artery, with or without graft
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Turning Point site for specific requirements. If your request is for INPATIENT services, 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 Turning Point. 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 Turning Point. If your request is for INPATIENT services, please submit the request to Trillium.

Insertion of intra-aortic balloon assist device through the ascending aorta

Service Code
33973 (CPT) Insertion of intra-aortic balloon assist device through the ascending aorta
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Turning Point site for specific requirements. If your request is for INPATIENT services, 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 Turning Point. 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 Turning Point. If your request is for INPATIENT services, please submit the request to Trillium.

Removal of intra-aortic balloon assist device from the ascending aorta, including repair of the ascending aorta, with or without graft

Service Code
33974 (CPT) Removal of intra-aortic balloon assist device from the ascending aorta, including repair of the ascending aorta, with or without graft
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Turning Point site for specific requirements. If your request is for INPATIENT services, 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 Turning Point. 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 Turning Point. If your request is for INPATIENT services, please submit the request to Trillium.

Insertion of ventricular assist device; extracorporeal, single ventricle

Service Code
33975 (CPT) Insertion of ventricular assist device; extracorporeal, single ventricle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Insertion of ventricular assist device; extracorporeal, biventricular

Service Code
33976 (CPT) Insertion of ventricular assist device; extracorporeal, biventricular
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal of ventricular assist device; extracorporeal, single ventricle

Service Code
33977 (CPT) Removal of ventricular assist device; extracorporeal, single ventricle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal of ventricular assist device; extracorporeal, biventricular

Service Code
33978 (CPT) Removal of ventricular assist device; extracorporeal, biventricular
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Insertion of ventricular assist device, implantable intracorporeal, single ventricle

Service Code
33979 (CPT) Insertion of ventricular assist device, implantable intracorporeal, single ventricle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal of ventricular assist device, implantable intracorporeal, single ventricle

Service Code
33980 (CPT) Removal of ventricular assist device, implantable intracorporeal, single ventricle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump

Service Code
33981 (CPT) Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass

Service Code
33982 (CPT) Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass

Service Code
33983 (CPT) Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), open, 6 years and older

Service Code
33984 (CPT) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), open, 6 years and older
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Turning Point site for specific requirements. If your request is for INPATIENT services, 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 Turning Point. 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 Turning Point. If your request is for INPATIENT services, please submit the request to Trillium.

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age

Service Code
33985 (CPT) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Turning Point site for specific requirements. If your request is for INPATIENT services, 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 Turning Point. 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 Turning Point. If your request is for INPATIENT services, please submit the request to Trillium.

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, 6 years and older

Service Code
33986 (CPT) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, 6 years and older
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Turning Point site for specific requirements. If your request is for INPATIENT services, 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 Turning Point. 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 Turning Point. If your request is for INPATIENT services, please submit the request to Trillium.

Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS (List separately in addition to code for primary procedure)

Service Code
33987 (CPT) Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS (List separately in addition to code for primary procedure)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Turning Point site for specific requirements. If your request is for INPATIENT services, 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 Turning Point. 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 Turning Point. If your request is for INPATIENT services, please submit the request to Trillium.

Insertion of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS

Service Code
33988 (CPT) Insertion of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Turning Point site for specific requirements. If your request is for INPATIENT services, 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 Turning Point. 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 Turning Point. If your request is for INPATIENT services, please submit the request to Trillium.

Removal of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS

Service Code
33989 (CPT) Removal of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Turning Point site for specific requirements. If your request is for INPATIENT services, 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 Turning Point. 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 Turning Point. If your request is for INPATIENT services, please submit the request to Trillium.

Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, arterial access only

Service Code
33990 (CPT) Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, arterial access only
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Turning Point site for specific requirements. If your request is for INPATIENT services, 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 Turning Point. 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 Turning Point. If your request is for INPATIENT services, please submit the request to Trillium.

Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, both arterial and venous access, with transseptal puncture

Service Code
33991 (CPT) Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, both arterial and venous access, with transseptal puncture
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Turning Point site for specific requirements. If your request is for INPATIENT services, 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 Turning Point. 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 Turning Point. If your request is for INPATIENT services, please submit the request to Trillium.