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
12465 Results
Cross-over vein graft to venous system
Service Code
34520 (CPT) Cross-over vein graft to venous system
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.
Saphenopopliteal vein anastomosis
Service Code
34530 (CPT) Saphenopopliteal vein anastomosis
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.
Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft ext
Service Code
34701 (CPT) Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft ext
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft ext
Service Code
34702 (CPT) Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft ext
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpreta
Service Code
34703 (CPT) Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpreta
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpreta
Service Code
34704 (CPT) Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpreta
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretat
Service Code
34705 (CPT) Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretat
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretat
Service Code
34706 (CPT) Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretat
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft exten
Service Code
34707 (CPT) Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft exten
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft exten
Service Code
34708 (CPT) Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft exten
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre-proced
Service Code
34709 (CPT) Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre-proced
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, all n
Service Code
34710 (CPT) Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, all n
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, all n
Service Code
34711 (CPT) Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, all n
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Transcatheter delivery of enhanced fixation device(s) to the endograft (eg, anchor, screw, tack) and all associated radiological supervision and interpretation
Service Code
34712 (CPT) Transcatheter delivery of enhanced fixation device(s) to the endograft (eg, anchor, screw, tack) and all associated radiological supervision and interpretation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in addition to code for primary procedure)
Service Code
34713 (CPT) Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Open femoral artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by groin incision, unilateral (List separately in addition to code for primary procedure)
Service Code
34714 (CPT) Open femoral artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by groin incision, unilateral (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Open axillary/subclavian artery exposure for delivery of endovascular prosthesis by infraclavicular or supraclavicular incision, unilateral (List separately in addition to code for primary procedure)
Service Code
34715 (CPT) Open axillary/subclavian artery exposure for delivery of endovascular prosthesis by infraclavicular or supraclavicular incision, unilateral (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Open axillary/subclavian artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by infraclavicular or supraclavicular incision, unilateral (List separately in addition to code for p
Service Code
34716 (CPT) Open axillary/subclavian artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by infraclavicular or supraclavicular incision, unilateral (List separately in addition to code for p
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Endovascular repair of iliac artery at the time of aorto-iliac artery endograft placement by deployment of an iliac branched endograft including pre-procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all asso
Service Code
34717 (CPT) Endovascular repair of iliac artery at the time of aorto-iliac artery endograft placement by deployment of an iliac branched endograft including pre-procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all asso
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Endovascular repair of iliac artery, not associated with placement of an aorto-iliac artery endograft at the same session, by deployment of an iliac branched endograft, including pre-procedure sizing and device selection, all ipsilateral selective iliac a
Service Code
34718 (CPT) Endovascular repair of iliac artery, not associated with placement of an aorto-iliac artery endograft at the same session, by deployment of an iliac branched endograft, including pre-procedure sizing and device selection, all ipsilateral selective iliac a
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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