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
Biopsy or excision of lymph node(s); open, inguinofemoral node(s)
Service Code
38531 (CPT) Biopsy or excision of lymph node(s); open, inguinofemoral node(s)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Dissection, deep jugular node(s)
Service Code
38542 (CPT) Dissection, deep jugular node(s)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of cystic hygroma, axillary or cervical; without deep neurovascular dissection
Service Code
38550 (CPT) Excision of cystic hygroma, axillary or cervical; without deep neurovascular dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of cystic hygroma, axillary or cervical; with deep neurovascular dissection
Service Code
38555 (CPT) Excision of cystic hygroma, axillary or cervical; with deep neurovascular dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic
Service Code
38562 (CPT) Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or splenic)
Service Code
38564 (CPT) Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or splenic)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple
Service Code
38570 (CPT) Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy
Service Code
38571 (CPT) Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple
Service Code
38572 (CPT) Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when perfo
Service Code
38573 (CPT) Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when perfo
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted laparoscopy procedure, lymphatic system
Service Code
38589 (CPT) Unlisted laparoscopy procedure, lymphatic system
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
Suprahyoid lymphadenectomy
Service Code
38700 (CPT) Suprahyoid lymphadenectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Cervical lymphadenectomy (complete)
Service Code
38720 (CPT) Cervical lymphadenectomy (complete)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Cervical lymphadenectomy (modified radical neck dissection)
Service Code
38724 (CPT) Cervical lymphadenectomy (modified radical neck dissection)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Axillary lymphadenectomy; superficial
Service Code
38740 (CPT) Axillary lymphadenectomy; superficial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Axillary lymphadenectomy; complete
Service Code
38745 (CPT) Axillary lymphadenectomy; complete
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Thoracic lymphadenectomy by thoracotomy, mediastinal and regional lymphadenectomy (List separately in addition to code for primary procedure)
Service Code
38746 (CPT) Thoracic lymphadenectomy by thoracotomy, mediastinal and regional lymphadenectomy (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
Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval nodes (List separately in addition to code for primary procedure)
Service Code
38747 (CPT) Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval nodes (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
Inguinofemoral lymphadenectomy, superficial, including Cloquet's node (separate procedure)
Service Code
38760 (CPT) Inguinofemoral lymphadenectomy, superficial, including Cloquet's node (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Inguinofemoral lymphadenectomy, superficial, in continuity with pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure)
Service Code
38765 (CPT) Inguinofemoral lymphadenectomy, superficial, in continuity with pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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