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

Filter By:
Clear Filters
12465 Results

Hepatectomy, resection of liver; partial lobectomy

Service Code
47120 (CPT) Hepatectomy, resection of liver; partial lobectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Hepatectomy, resection of liver; trisegmentectomy

Service Code
47122 (CPT) Hepatectomy, resection of liver; trisegmentectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Hepatectomy, resection of liver; total left lobectomy

Service Code
47125 (CPT) Hepatectomy, resection of liver; total left lobectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Hepatectomy, resection of liver; total right lobectomy

Service Code
47130 (CPT) Hepatectomy, resection of liver; total right lobectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Donor hepatectomy (including cold preservation), from cadaver donor

Service Code
47133 (CPT) Donor hepatectomy (including cold preservation), from cadaver donor
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

Liver allotransplantation, orthotopic, partial or whole, from cadaver or living donor, any age

Service Code
47135 (CPT) Liver allotransplantation, orthotopic, partial or whole, from cadaver or living donor, any age
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

Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III)

Service Code
47140 (CPT) Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III)
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

Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III and IV)

Service Code
47141 (CPT) Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III and IV)
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

Donor hepatectomy (including cold preservation), from living donor; total right lobectomy (segments V, VI, VII and VIII)

Service Code
47142 (CPT) Donor hepatectomy (including cold preservation), from living donor; total right lobectomy (segments V, VI, VII and VIII)
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 standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and comm

Service Code
47143 (CPT) Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and comm
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 standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and comm

Service Code
47144 (CPT) Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and comm
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 standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and comm

Service Code
47145 (CPT) Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and comm
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 liver graft prior to allotransplantation; venous anastomosis, each

Service Code
47146 (CPT) Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; 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 liver graft prior to allotransplantation; arterial anastomosis, each

Service Code
47147 (CPT) Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; 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

Marsupialization of cyst or abscess of liver

Service Code
47300 (CPT) Marsupialization of cyst or abscess of liver
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Management of liver hemorrhage; simple suture of liver wound or injury

Service Code
47350 (CPT) Management of liver hemorrhage; simple suture of liver wound or injury
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Management of liver hemorrhage; complex suture of liver wound or injury, with or without hepatic artery ligation

Service Code
47360 (CPT) Management of liver hemorrhage; complex suture of liver wound or injury, with or without hepatic artery ligation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Management of liver hemorrhage; exploration of hepatic wound, extensive debridement, coagulation and/or suture, with or without packing of liver

Service Code
47361 (CPT) Management of liver hemorrhage; exploration of hepatic wound, extensive debridement, coagulation and/or suture, with or without packing of liver
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Management of liver hemorrhage; re-exploration of hepatic wound for removal of packing

Service Code
47362 (CPT) Management of liver hemorrhage; re-exploration of hepatic wound for removal of packing
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency

Service Code
47370 (CPT) Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency
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.

Conditional Requirements

Pre-authorization required for all providers when billed with an Ablative Dx. For all others, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Trillium.