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
Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3
Service Code
49615 (CPT) Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3
Service Code
49616 (CPT) Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); gr
Service Code
49617 (CPT) Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); gr
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); gr
Service Code
49618 (CPT) Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); gr
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of parastomal hernia, any approach (ie, open, laparoscopic, robotic), initial or recurrent, including implantation of mesh or other prosthesis, when performed; reducible
Service Code
49621 (CPT) Repair of parastomal hernia, any approach (ie, open, laparoscopic, robotic), initial or recurrent, including implantation of mesh or other prosthesis, when performed; reducible
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of parastomal hernia, any approach (ie, open, laparoscopic, robotic), initial or recurrent, including implantation of mesh or other prosthesis, when performed; incarcerated or strangulated
Service Code
49622 (CPT) Repair of parastomal hernia, any approach (ie, open, laparoscopic, robotic), initial or recurrent, including implantation of mesh or other prosthesis, when performed; incarcerated or strangulated
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Removal of total or near total non-infected mesh or other prosthesis at the time of initial or recurrent anterior abdominal hernia repair or parastomal hernia repair, any approach (ie, open, laparoscopic, robotic) (List separately in addition to code for
Service Code
49623 (CPT) Removal of total or near total non-infected mesh or other prosthesis at the time of initial or recurrent anterior abdominal hernia repair or parastomal hernia repair, any approach (ie, open, laparoscopic, robotic) (List separately in addition to code for
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Laparoscopy, surgical; repair initial inguinal hernia
Service Code
49650 (CPT) Laparoscopy, surgical; repair initial inguinal hernia
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
Laparoscopy, surgical; repair recurrent inguinal hernia
Service Code
49651 (CPT) Laparoscopy, surgical; repair recurrent inguinal hernia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy
Service Code
49659 (CPT) Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy
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
Suture, secondary, of abdominal wall for evisceration or dehiscence
Service Code
49900 (CPT) Suture, secondary, of abdominal wall for evisceration or dehiscence
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Omental flap, extra-abdominal (eg, for reconstruction of sternal and chest wall defects)
Service Code
49904 (CPT) Omental flap, extra-abdominal (eg, for reconstruction of sternal and chest wall defects)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Omental flap, intra-abdominal (List separately in addition to code for primary procedure)
Service Code
49905 (CPT) Omental flap, intra-abdominal (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
Free omental flap with microvascular anastomosis
Service Code
49906 (CPT) Free omental flap with microvascular anastomosis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted procedure, abdomen, peritoneum and omentum
Service Code
49999 (CPT) Unlisted 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
Renal exploration, not necessitating other specific procedures
Service Code
50010 (CPT) Renal exploration, not necessitating other specific procedures
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Drainage of perirenal or renal abscess, open
Service Code
50020 (CPT) Drainage of perirenal or renal abscess, open
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nephrostomy, nephrotomy with drainage
Service Code
50040 (CPT) Nephrostomy, nephrotomy with drainage
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nephrotomy, with exploration
Service Code
50045 (CPT) Nephrotomy, with exploration
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nephrolithotomy; removal of calculus
Service Code
50060 (CPT) Nephrolithotomy; removal of calculus
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
See something that needs to be updated?
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.