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
Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate procedure)
Service Code
44500 (CPT) Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation
Service Code
44602 (CPT) Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; multiple perforations
Service Code
44603 (CPT) Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; multiple perforations
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); without colostomy
Service Code
44604 (CPT) Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); without colostomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); with colostomy
Service Code
44605 (CPT) Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); with colostomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or without dilation, for intestinal obstruction
Service Code
44615 (CPT) Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or without dilation, for intestinal obstruction
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of enterostomy, large or small intestine;
Service Code
44620 (CPT) Closure of enterostomy, large or small intestine;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of enterostomy, large or small intestine; with resection and anastomosis other than colorectal
Service Code
44625 (CPT) Closure of enterostomy, large or small intestine; with resection and anastomosis other than colorectal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of enterostomy, large or small intestine; with resection and colorectal anastomosis (eg, closure of Hartmann type procedure)
Service Code
44626 (CPT) Closure of enterostomy, large or small intestine; with resection and colorectal anastomosis (eg, closure of Hartmann type procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of intestinal cutaneous fistula
Service Code
44640 (CPT) Closure of intestinal cutaneous fistula
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of enteroenteric or enterocolic fistula
Service Code
44650 (CPT) Closure of enteroenteric or enterocolic fistula
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of enterovesical fistula; without intestinal or bladder resection
Service Code
44660 (CPT) Closure of enterovesical fistula; without intestinal or bladder resection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of enterovesical fistula; with intestine and/or bladder resection
Service Code
44661 (CPT) Closure of enterovesical fistula; with intestine and/or bladder resection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Intestinal plication (separate procedure)
Service Code
44680 (CPT) Intestinal plication (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Exclusion of small intestine from pelvis by mesh or other prosthesis, or native tissue (eg, bladder or omentum)
Service Code
44700 (CPT) Exclusion of small intestine from pelvis by mesh or other prosthesis, or native tissue (eg, bladder or omentum)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Intraoperative colonic lavage (List separately in addition to code for primary procedure)
Service Code
44701 (CPT) Intraoperative colonic lavage (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
Preparation of fecal microbiota for instillation, including assessment of donor specimen
Service Code
44705 (CPT) Preparation of fecal microbiota for instillation, including assessment of donor specimen
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein
Service Code
44715 (CPT) Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health
Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each
Service Code
44720 (CPT) Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health
Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each
Service Code
44721 (CPT) Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health
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