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
Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis;
Service Code
51590 (CPT) Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes
Service Code
51595 (CPT) Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder
Service Code
51596 (CPT) Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy, with removal of bladder and ureteral transplantations, with or without hysterectomy and/or abdominoperineal resection of rectum and colon and colostomy, or any combination there
Service Code
51597 (CPT) Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy, with removal of bladder and ureteral transplantations, with or without hysterectomy and/or abdominoperineal resection of rectum and colon and colostomy, or any combination there
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Injection procedure for cystography or voiding urethrocystography
Service Code
51600 (CPT) Injection procedure for cystography or voiding urethrocystography
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Injection procedure and placement of chain for contrast and/or chain urethrocystography
Service Code
51605 (CPT) Injection procedure and placement of chain for contrast and/or chain urethrocystography
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Injection procedure for retrograde urethrocystography
Service Code
51610 (CPT) Injection procedure for retrograde urethrocystography
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Bladder irrigation, simple, lavage and/or instillation
Service Code
51700 (CPT) Bladder irrigation, simple, lavage and/or instillation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine)
Service Code
51701 (CPT) Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Insertion of temporary indwelling bladder catheter; simple (eg, Foley)
Service Code
51702 (CPT) Insertion of temporary indwelling bladder catheter; simple (eg, Foley)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon)
Service Code
51703 (CPT) Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Change of cystostomy tube; simple
Service Code
51705 (CPT) Change of cystostomy tube; simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Change of cystostomy tube; complicated
Service Code
51710 (CPT) Change of cystostomy tube; complicated
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck
Service Code
51715 (CPT) Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck
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
Bladder instillation of anticarcinogenic agent (including retention time)
Service Code
51720 (CPT) Bladder instillation of anticarcinogenic agent (including retention time)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Simple cystometrogram (CMG) (eg, spinal manometer)
Service Code
51725 (CPT) Simple cystometrogram (CMG) (eg, spinal manometer)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Complex cystometrogram (ie, calibrated electronic equipment);
Service Code
51726 (CPT) Complex cystometrogram (ie, calibrated electronic equipment);
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Complex cystometrogram (ie, calibrated electronic equipment); with urethral pressure profile studies (ie, urethral closure pressure profile), any technique
Service Code
51727 (CPT) Complex cystometrogram (ie, calibrated electronic equipment); with urethral pressure profile studies (ie, urethral closure pressure profile), any technique
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure), any technique
Service Code
51728 (CPT) Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure), any technique
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique
Service Code
51729 (CPT) Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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