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
Nephrolithotomy; secondary surgical operation for calculus
Service Code
50065 (CPT) Nephrolithotomy; secondary surgical operation for calculus
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nephrolithotomy; complicated by congenital kidney abnormality
Service Code
50070 (CPT) Nephrolithotomy; complicated by congenital kidney abnormality
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nephrolithotomy; removal of large staghorn calculus filling renal pelvis and calyces (including anatrophic pyelolithotomy)
Service Code
50075 (CPT) Nephrolithotomy; removal of large staghorn calculus filling renal pelvis and calyces (including anatrophic pyelolithotomy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm
Service Code
50080 (CPT) Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm
Service Code
50081 (CPT) Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Transection or repositioning of aberrant renal vessels (separate procedure)
Service Code
50100 (CPT) Transection or repositioning of aberrant renal vessels (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Pyelotomy; with exploration
Service Code
50120 (CPT) Pyelotomy; with exploration
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Pyelotomy; with drainage, pyelostomy
Service Code
50125 (CPT) Pyelotomy; with drainage, pyelostomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Pyelotomy; with removal of calculus (pyelolithotomy, pelviolithotomy, including coagulum pyelolithotomy)
Service Code
50130 (CPT) Pyelotomy; with removal of calculus (pyelolithotomy, pelviolithotomy, including coagulum pyelolithotomy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Renal biopsy; percutaneous, by trocar or needle
Service Code
50200 (CPT) Renal biopsy; percutaneous, by trocar or needle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Renal biopsy; by surgical exposure of kidney
Service Code
50205 (CPT) Renal biopsy; by surgical exposure of kidney
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nephrectomy, including partial ureterectomy, any open approach including rib resection;
Service Code
50220 (CPT) Nephrectomy, including partial ureterectomy, any open approach including rib resection;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nephrectomy, including partial ureterectomy, any open approach including rib resection; complicated because of previous surgery on same kidney
Service Code
50225 (CPT) Nephrectomy, including partial ureterectomy, any open approach including rib resection; complicated because of previous surgery on same kidney
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy
Service Code
50230 (CPT) Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nephrectomy with total ureterectomy and bladder cuff; through same incision
Service Code
50234 (CPT) Nephrectomy with total ureterectomy and bladder cuff; through same incision
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nephrectomy with total ureterectomy and bladder cuff; through separate incision
Service Code
50236 (CPT) Nephrectomy with total ureterectomy and bladder cuff; through separate incision
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nephrectomy, partial
Service Code
50240 (CPT) Nephrectomy, partial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed
Service Code
50250 (CPT) Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision or unroofing of cyst(s) of kidney
Service Code
50280 (CPT) Excision or unroofing of cyst(s) of kidney
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of perinephric cyst
Service Code
50290 (CPT) Excision of perinephric cyst
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.