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

Unlisted procedure, vascular surgery

Service Code
37799 (CPT) Unlisted procedure, vascular surgery
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

Splenectomy; total (separate procedure)

Service Code
38100 (CPT) Splenectomy; total (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Splenectomy; partial (separate procedure)

Service Code
38101 (CPT) Splenectomy; partial (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Splenectomy; total, en bloc for extensive disease, in conjunction with other procedure (List in addition to code for primary procedure)

Service Code
38102 (CPT) Splenectomy; total, en bloc for extensive disease, in conjunction with other procedure (List 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

Repair of ruptured spleen (splenorrhaphy) with or without partial splenectomy

Service Code
38115 (CPT) Repair of ruptured spleen (splenorrhaphy) with or without partial splenectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Laparoscopy, surgical, splenectomy

Service Code
38120 (CPT) Laparoscopy, surgical, splenectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted laparoscopy procedure, spleen

Service Code
38129 (CPT) Unlisted laparoscopy procedure, spleen
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

Injection procedure for splenoportography

Service Code
38200 (CPT) Injection procedure for splenoportography
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Management of recipient hematopoietic progenitor cell donor search and cell acquisition

Service Code
38204 (CPT) Management of recipient hematopoietic progenitor cell donor search and cell acquisition
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health

Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic

Service Code
38205 (CPT) Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health

Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous

Service Code
38206 (CPT) Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health

Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage

Service Code
38207 (CPT) Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health

Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor

Service Code
38208 (CPT) Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health

Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor

Service Code
38209 (CPT) Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health

Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion

Service Code
38210 (CPT) Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health

Transplant preparation of hematopoietic progenitor cells; red blood cell removal

Service Code
38212 (CPT) Transplant preparation of hematopoietic progenitor cells; red blood cell removal
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health

Transplant preparation of hematopoietic progenitor cells; platelet depletion

Service Code
38213 (CPT) Transplant preparation of hematopoietic progenitor cells; platelet depletion
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health

Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion

Service Code
38214 (CPT) Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health

Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer

Service Code
38215 (CPT) Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health

Diagnostic bone marrow; aspiration(s)

Service Code
38220 (CPT) Diagnostic bone marrow; aspiration(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health