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
Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, including imaging guidance, if performed, single or multiple (List sepa
Service Code
49327 (CPT) Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, including imaging guidance, if performed, single or multiple (List sepa
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted laparoscopy procedure, abdomen, peritoneum and omentum
Service Code
49329 (CPT) Unlisted laparoscopy procedure, abdomen, peritoneum and omentum
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
Injection of air or contrast into peritoneal cavity (separate procedure)
Service Code
49400 (CPT) Injection of air or contrast into peritoneal cavity (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Removal of peritoneal foreign body from peritoneal cavity
Service Code
49402 (CPT) Removal of peritoneal foreign body from peritoneal cavity
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous
Service Code
49405 (CPT) Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, percutaneous
Service Code
49406 (CPT) Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, percutaneous
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, transvaginal or transrectal
Service Code
49407 (CPT) Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, transvaginal or transrectal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or multiple
Service Code
49411 (CPT) Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or multiple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), open, intra-abdominal, intrapelvic, and/or retroperitoneum, including image guidance, if performed, single or multiple (List separately in addition to co
Service Code
49412 (CPT) Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), open, intra-abdominal, intrapelvic, and/or retroperitoneum, including image guidance, if performed, single or multiple (List separately in addition to co
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Insertion of tunneled intraperitoneal catheter (eg, dialysis, intraperitoneal chemotherapy instillation, management of ascites), complete procedure, including imaging guidance, catheter placement, contrast injection when performed, and radiological superv
Service Code
49418 (CPT) Insertion of tunneled intraperitoneal catheter (eg, dialysis, intraperitoneal chemotherapy instillation, management of ascites), complete procedure, including imaging guidance, catheter placement, contrast injection when performed, and radiological superv
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Insertion of tunneled intraperitoneal catheter, with subcutaneous port (ie, totally implantable)
Service Code
49419 (CPT) Insertion of tunneled intraperitoneal catheter, with subcutaneous port (ie, totally implantable)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Insertion of tunneled intraperitoneal catheter for dialysis, open
Service Code
49421 (CPT) Insertion of tunneled intraperitoneal catheter for dialysis, open
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Removal of tunneled intraperitoneal catheter
Service Code
49422 (CPT) Removal of tunneled intraperitoneal catheter
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Exchange of previously placed abscess or cyst drainage catheter under radiological guidance (separate procedure)
Service Code
49423 (CPT) Exchange of previously placed abscess or cyst drainage catheter under radiological guidance (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or tube (separate procedure)
Service Code
49424 (CPT) Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or tube (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Insertion of peritoneal-venous shunt
Service Code
49425 (CPT) Insertion of peritoneal-venous shunt
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Revision of peritoneal-venous shunt
Service Code
49426 (CPT) Revision of peritoneal-venous shunt
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Injection procedure (eg, contrast media) for evaluation of previously placed peritoneal-venous shunt
Service Code
49427 (CPT) Injection procedure (eg, contrast media) for evaluation of previously placed peritoneal-venous shunt
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Ligation of peritoneal-venous shunt
Service Code
49428 (CPT) Ligation of peritoneal-venous shunt
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Removal of peritoneal-venous shunt
Service Code
49429 (CPT) Removal of peritoneal-venous shunt
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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