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
Esophagojejunostomy (without total gastrectomy); thoracic approach
Service Code
43341 (CPT) Esophagojejunostomy (without total gastrectomy); thoracic approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Esophagostomy, fistulization of esophagus, external; thoracic approach
Service Code
43351 (CPT) Esophagostomy, fistulization of esophagus, external; thoracic approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Esophagostomy, fistulization of esophagus, external; cervical approach
Service Code
43352 (CPT) Esophagostomy, fistulization of esophagus, external; cervical approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; with stomach, with or without pyloroplasty
Service Code
43360 (CPT) Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; with stomach, with or without pyloroplasty
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and
Service Code
43361 (CPT) Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Ligation, direct, esophageal varices
Service Code
43400 (CPT) Ligation, direct, esophageal varices
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Ligation or stapling at gastroesophageal junction for pre-existing esophageal perforation
Service Code
43405 (CPT) Ligation or stapling at gastroesophageal junction for pre-existing esophageal perforation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of esophageal wound or injury; cervical approach
Service Code
43410 (CPT) Suture of esophageal wound or injury; cervical approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of esophageal wound or injury; transthoracic or transabdominal approach
Service Code
43415 (CPT) Suture of esophageal wound or injury; transthoracic or transabdominal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of esophagostomy or fistula; cervical approach
Service Code
43420 (CPT) Closure of esophagostomy or fistula; cervical approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of esophagostomy or fistula; transthoracic or transabdominal approach
Service Code
43425 (CPT) Closure of esophagostomy or fistula; transthoracic or transabdominal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Dilation of esophagus, by unguided sound or bougie, single or multiple passes
Service Code
43450 (CPT) Dilation of esophagus, by unguided sound or bougie, single or multiple passes
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Dilation of esophagus, over guide wire
Service Code
43453 (CPT) Dilation of esophagus, over guide wire
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Esophagogastric tamponade, with balloon (Sengstaken type)
Service Code
43460 (CPT) Esophagogastric tamponade, with balloon (Sengstaken type)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Free jejunum transfer with microvascular anastomosis
Service Code
43496 (CPT) Free jejunum transfer with microvascular anastomosis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM])
Service Code
43497 (CPT) Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM])
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted procedure, esophagus
Service Code
43499 (CPT) Unlisted procedure, esophagus
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
Gastrotomy; with exploration or foreign body removal
Service Code
43500 (CPT) Gastrotomy; with exploration or foreign body removal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Gastrotomy; with suture repair of bleeding ulcer
Service Code
43501 (CPT) Gastrotomy; with suture repair of bleeding ulcer
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Gastrotomy; with suture repair of pre-existing esophagogastric laceration (eg, Mallory-Weiss)
Service Code
43502 (CPT) Gastrotomy; with suture repair of pre-existing esophagogastric laceration (eg, Mallory-Weiss)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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