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

Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical uroflowmeter)

Service Code
51736 (CPT) Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical uroflowmeter)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Complex uroflowmetry (eg, calibrated electronic equipment)

Service Code
51741 (CPT) Complex uroflowmetry (eg, calibrated electronic equipment)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique

Service Code
51784 (CPT) Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Needle electromyography studies (EMG) of anal or urethral sphincter, any technique

Service Code
51785 (CPT) Needle electromyography studies (EMG) of anal or urethral sphincter, any technique
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stimulus evoked response (eg, measurement of bulbocavernosus reflex latency time)

Service Code
51792 (CPT) Stimulus evoked response (eg, measurement of bulbocavernosus reflex latency time)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure)

Service Code
51797 (CPT) Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (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

Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging

Service Code
51798 (CPT) Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck (anterior Y-plasty, vesical fundus resection), any procedure, with or without wedge resection of posterior vesical neck

Service Code
51800 (CPT) Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck (anterior Y-plasty, vesical fundus resection), any procedure, with or without wedge resection of posterior vesical neck
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Cystourethroplasty with unilateral or bilateral ureteroneocystostomy

Service Code
51820 (CPT) Cystourethroplasty with unilateral or bilateral ureteroneocystostomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); simple

Service Code
51840 (CPT) Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); complicated (eg, secondary repair)

Service Code
51841 (CPT) Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); complicated (eg, secondary repair)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Abdomino-vaginal vesical neck suspension, with or without endoscopic control (eg, Stamey, Raz, modified Pereyra)

Service Code
51845 (CPT) Abdomino-vaginal vesical neck suspension, with or without endoscopic control (eg, Stamey, Raz, modified Pereyra)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Cystorrhaphy, suture of bladder wound, injury or rupture; simple

Service Code
51860 (CPT) Cystorrhaphy, suture of bladder wound, injury or rupture; simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Cystorrhaphy, suture of bladder wound, injury or rupture; complicated

Service Code
51865 (CPT) Cystorrhaphy, suture of bladder wound, injury or rupture; complicated
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Closure of cystostomy (separate procedure)

Service Code
51880 (CPT) Closure of cystostomy (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Closure of vesicovaginal fistula, abdominal approach

Service Code
51900 (CPT) Closure of vesicovaginal fistula, abdominal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Closure of vesicouterine fistula;

Service Code
51920 (CPT) Closure of vesicouterine fistula;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Closure of vesicouterine fistula; with hysterectomy

Service Code
51925 (CPT) Closure of vesicouterine fistula; with hysterectomy
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.

Authorization Guidelines

The following diagnoses are accepted as validation of medical necessity for hysterectomies: Malignant and pre-malignant lesions of the female reproductive tract, Endometriosis Adenomyosis, Leiomyomas or fibroids, Salpingitis and oophoritis, Mild to moderate cervical dysplasia, when prior conservative procedures failed.

Hyperplasia of the endometrium Dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia Inflammatory peritonitis Intractable procidentia (prolapsed uterus) Perforation of the uterus by IUD Class IV or V pap smear Prophylactic oophorectomy for positive family history of BRCA-1 (breast cancer gene) Traumatic injury to the uterus with irreparable damage Complications of childbirth such as uterine rupture or intractable hemorrhage (for Medicaid beneficiaries only)

Limits

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.

Length of Stay

Covered once in a lifetime per individual

Exclusions

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.

Diagnosis Requirements

Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.

Place of Service

Inpatient hospital, Outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

1E-1, Hysterectomy

Service Code
51925 (CPT) Closure of vesicouterine fistula; with hysterectomy
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.

Limits

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.

Length of Stay

Covered once in a lifetime per individual

Exclusions

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.

Diagnosis Requirements

Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.

Place of Service

Inpatient hospital, Outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Closure, exstrophy of bladder

Service Code
51940 (CPT) Closure, exstrophy of bladder
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required