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
Adenoidectomy, primary; younger than age 12
Service Code
42830 (CPT) Adenoidectomy, primary; younger than age 12
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Adenoidectomy, primary; age 12 or over
Service Code
42831 (CPT) Adenoidectomy, primary; age 12 or over
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Adenoidectomy, secondary; younger than age 12
Service Code
42835 (CPT) Adenoidectomy, 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
Adenoidectomy, secondary; age 12 or over
Service Code
42836 (CPT) Adenoidectomy, 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
Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure
Service Code
42842 (CPT) Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap (eg, tongue, buccal)
Service Code
42844 (CPT) Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap (eg, tongue, buccal)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with other flap
Service Code
42845 (CPT) Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with other flap
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of tonsil tags
Service Code
42860 (CPT) Excision of tonsil tags
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision or destruction lingual tonsil, any method (separate procedure)
Service Code
42870 (CPT) Excision or destruction lingual tonsil, any method (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Limited pharyngectomy
Service Code
42890 (CPT) Limited pharyngectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Resection of lateral pharyngeal wall or pyriform sinus, direct closure by advancement of lateral and posterior pharyngeal walls
Service Code
42892 (CPT) Resection of lateral pharyngeal wall or pyriform sinus, direct closure by advancement of lateral and posterior pharyngeal walls
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Resection of pharyngeal wall requiring closure with myocutaneous or fasciocutaneous flap or free muscle, skin, or fascial flap with microvascular anastomosis
Service Code
42894 (CPT) Resection of pharyngeal wall requiring closure with myocutaneous or fasciocutaneous flap or free muscle, skin, or fascial flap with microvascular anastomosis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture pharynx for wound or injury
Service Code
42900 (CPT) Suture pharynx for wound or injury
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Pharyngoplasty (plastic or reconstructive operation on pharynx)
Service Code
42950 (CPT) Pharyngoplasty (plastic or reconstructive operation on pharynx)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Pharyngoesophageal repair
Service Code
42953 (CPT) Pharyngoesophageal repair
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Pharyngostomy (fistulization of pharynx, external for feeding)
Service Code
42955 (CPT) Pharyngostomy (fistulization of pharynx, external for feeding)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple
Service Code
42960 (CPT) Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); complicated, requiring hospitalization
Service Code
42961 (CPT) Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); complicated, requiring hospitalization
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); with secondary surgical intervention
Service Code
42962 (CPT) Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); with secondary surgical intervention
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); simple, with posterior nasal packs, with or without anterior packs and/or cautery
Service Code
42970 (CPT) Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); simple, with posterior nasal packs, with or without anterior packs and/or cautery
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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