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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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Bypass graft, with vein; aortosubclavian, aortoinnominate, or aortocarotid

Service Code
35526 (CPT) Bypass graft, with vein; aortosubclavian, aortoinnominate, or aortocarotid
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.

Bypass graft, with vein; aortoceliac or aortomesenteric

Service Code
35531 (CPT) Bypass graft, with vein; aortoceliac or aortomesenteric
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.

Bypass graft, with vein; axillary-femoral-femoral

Service Code
35533 (CPT) Bypass graft, with vein; axillary-femoral-femoral
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.

Bypass graft, with vein; hepatorenal

Service Code
35535 (CPT) Bypass graft, with vein; hepatorenal
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.

Bypass graft, with vein; splenorenal

Service Code
35536 (CPT) Bypass graft, with vein; splenorenal
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.

Bypass graft, with vein; aortoiliac

Service Code
35537 (CPT) Bypass graft, with vein; aortoiliac
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.

Bypass graft, with vein; aortobi-iliac

Service Code
35538 (CPT) Bypass graft, with vein; aortobi-iliac
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.

Bypass graft, with vein; aortofemoral

Service Code
35539 (CPT) Bypass graft, with vein; aortofemoral
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.

Bypass graft, with vein; aortobifemoral

Service Code
35540 (CPT) Bypass graft, with vein; aortobifemoral
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.

Bypass graft, with vein; femoral-popliteal

Service Code
35556 (CPT) Bypass graft, with vein; femoral-popliteal
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.

Bypass graft, with vein; femoral-femoral

Service Code
35558 (CPT) Bypass graft, with vein; femoral-femoral
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.

Bypass graft, with vein; aortorenal

Service Code
35560 (CPT) Bypass graft, with vein; aortorenal
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.

Bypass graft, with vein; ilioiliac

Service Code
35563 (CPT) Bypass graft, with vein; ilioiliac
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.

Bypass graft, with vein; iliofemoral

Service Code
35565 (CPT) Bypass graft, with vein; iliofemoral
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.

Bypass graft, with vein; femoral-anterior tibial, posterior tibial, peroneal artery or other distal vessels

Service Code
35566 (CPT) Bypass graft, with vein; femoral-anterior tibial, posterior tibial, peroneal artery or other distal vessels
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.

Bypass graft, with vein; tibial-tibial, peroneal-tibial, or tibial/peroneal trunk-tibial

Service Code
35570 (CPT) Bypass graft, with vein; tibial-tibial, peroneal-tibial, or tibial/peroneal trunk-tibial
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.

Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels

Service Code
35571 (CPT) Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels
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.

Harvest of femoropopliteal vein, 1 segment, for vascular reconstruction procedure (eg, aortic, vena caval, coronary, peripheral artery) (List separately in addition to code for primary procedure)

Service Code
35572 (CPT) Harvest of femoropopliteal vein, 1 segment, for vascular reconstruction procedure (eg, aortic, vena caval, coronary, peripheral artery) (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.

In-situ vein bypass; femoral-popliteal

Service Code
35583 (CPT) In-situ vein bypass; femoral-popliteal
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.

In-situ vein bypass; femoral-anterior tibial, posterior tibial, or peroneal artery

Service Code
35585 (CPT) In-situ vein bypass; femoral-anterior tibial, posterior tibial, or peroneal artery
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.