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
Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure)
Service Code
38770 (CPT) 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
Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes (separate procedure)
Service Code
38780 (CPT) Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Injection procedure; lymphangiography
Service Code
38790 (CPT) Injection procedure; lymphangiography
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Injection procedure; radioactive tracer for identification of sentinel node
Service Code
38792 (CPT) Injection procedure; radioactive tracer for identification of sentinel node
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Cannulation, thoracic duct
Service Code
38794 (CPT) Cannulation, thoracic duct
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure)
Service Code
38900 (CPT) Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (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
Unlisted procedure, hemic or lymphatic system
Service Code
38999 (CPT) Unlisted procedure, hemic or 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
Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical approach
Service Code
39000 (CPT) Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transthoracic approach, including either transthoracic or median sternotomy
Service Code
39010 (CPT) Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transthoracic approach, including either transthoracic or median sternotomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Resection of mediastinal cyst
Service Code
39200 (CPT) Resection of mediastinal cyst
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Resection of mediastinal tumor
Service Code
39220 (CPT) Resection of mediastinal tumor
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Mediastinoscopy; includes biopsy(ies) of mediastinal mass (eg, lymphoma), when performed
Service Code
39401 (CPT) Mediastinoscopy; includes biopsy(ies) of mediastinal mass (eg, lymphoma), when performed
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Mediastinoscopy; with lymph node biopsy(ies) (eg, lung cancer staging)
Service Code
39402 (CPT) Mediastinoscopy; with lymph node biopsy(ies) (eg, lung cancer staging)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted procedure, mediastinum
Service Code
39499 (CPT) Unlisted procedure, mediastinum
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
Repair, laceration of diaphragm, any approach
Service Code
39501 (CPT) Repair, laceration of diaphragm, any approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia
Service Code
39503 (CPT) Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair, diaphragmatic hernia (other than neonatal), traumatic; acute
Service Code
39540 (CPT) Repair, diaphragmatic hernia (other than neonatal), traumatic; acute
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic
Service Code
39541 (CPT) Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Imbrication of diaphragm for eventration, transthoracic or transabdominal, paralytic or nonparalytic
Service Code
39545 (CPT) Imbrication of diaphragm for eventration, transthoracic or transabdominal, paralytic or nonparalytic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Resection, diaphragm; with simple repair (eg, primary suture)
Service Code
39560 (CPT) Resection, diaphragm; with simple repair (eg, primary suture)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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