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
Injection procedure for sialography
Service Code
42550 (CPT) Injection procedure for sialography
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure salivary fistula
Service Code
42600 (CPT) Closure salivary fistula
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Dilation salivary duct
Service Code
42650 (CPT) Dilation salivary duct
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Dilation and catheterization of salivary duct, with or without injection
Service Code
42660 (CPT) Dilation and catheterization of salivary duct, with or without injection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Ligation salivary duct, intraoral
Service Code
42665 (CPT) Ligation salivary duct, intraoral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted procedure, salivary glands or ducts
Service Code
42699 (CPT) Unlisted procedure, salivary glands or ducts
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
Incision and drainage abscess; peritonsillar
Service Code
42700 (CPT) Incision and drainage abscess; peritonsillar
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Incision and drainage abscess; retropharyngeal or parapharyngeal, intraoral approach
Service Code
42720 (CPT) Incision and drainage abscess; retropharyngeal or parapharyngeal, intraoral approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Incision and drainage abscess; retropharyngeal or parapharyngeal, external approach
Service Code
42725 (CPT) Incision and drainage abscess; retropharyngeal or parapharyngeal, external approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Biopsy; oropharynx
Service Code
42800 (CPT) Biopsy; oropharynx
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Biopsy; nasopharynx, visible lesion, simple
Service Code
42804 (CPT) Biopsy; nasopharynx, visible lesion, simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Biopsy; nasopharynx, survey for unknown primary lesion
Service Code
42806 (CPT) Biopsy; nasopharynx, survey for unknown primary lesion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision or destruction of lesion of pharynx, any method
Service Code
42808 (CPT) Excision or destruction of lesion of pharynx, any method
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Removal of foreign body from pharynx
Service Code
42809 (CPT) Removal of foreign body from pharynx
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues
Service Code
42810 (CPT) Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx
Service Code
42815 (CPT) Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Tonsillectomy and adenoidectomy; younger than age 12
Service Code
42820 (CPT) Tonsillectomy and adenoidectomy; younger than age 12
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Tonsillectomy and adenoidectomy; age 12 or over
Service Code
42821 (CPT) Tonsillectomy and adenoidectomy; age 12 or over
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Tonsillectomy, primary or secondary; younger than age 12
Service Code
42825 (CPT) Tonsillectomy, primary or secondary; younger than age 12
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Tonsillectomy, primary or secondary; age 12 or over
Service Code
42826 (CPT) Tonsillectomy, primary or secondary; age 12 or over
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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