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Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12465 Results

Excision of urethral diverticulum (separate procedure); female

Service Code
53230 (CPT) Excision of urethral diverticulum (separate procedure); female
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of urethral diverticulum (separate procedure); male

Service Code
53235 (CPT) Excision of urethral diverticulum (separate procedure); male
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Marsupialization of urethral diverticulum, male or female

Service Code
53240 (CPT) Marsupialization of urethral diverticulum, male or female
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of bulbourethral gland (Cowper's gland)

Service Code
53250 (CPT) Excision of bulbourethral gland (Cowper's gland)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision or fulguration; urethral polyp(s), distal urethra

Service Code
53260 (CPT) Excision or fulguration; urethral polyp(s), distal urethra
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision or fulguration; urethral caruncle

Service Code
53265 (CPT) Excision or fulguration; urethral caruncle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision or fulguration; Skene's glands

Service Code
53270 (CPT) Excision or fulguration; Skene's glands
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision or fulguration; urethral prolapse

Service Code
53275 (CPT) Excision or fulguration; urethral prolapse
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Urethroplasty; first stage, for fistula, diverticulum, or stricture (eg, Johannsen type)

Service Code
53400 (CPT) Urethroplasty; first stage, for fistula, diverticulum, or stricture (eg, Johannsen type)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Urethroplasty; second stage (formation of urethra), including urinary diversion

Service Code
53405 (CPT) Urethroplasty; second stage (formation of urethra), including urinary diversion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Urethroplasty, 1-stage reconstruction of male anterior urethra

Service Code
53410 (CPT) Urethroplasty, 1-stage reconstruction of male anterior urethra
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

Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra

Service Code
53415 (CPT) Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra
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

Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage

Service Code
53420 (CPT) Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage
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

Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second stage

Service Code
53425 (CPT) Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second stage
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

Urethroplasty, reconstruction of female urethra

Service Code
53430 (CPT) Urethroplasty, reconstruction of female urethra
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.

Conditional Requirements

Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Trillium.

Urethroplasty with tubularization of posterior urethra and/or lower bladder for incontinence (eg, Tenago, Leadbetter procedure)

Service Code
53431 (CPT) Urethroplasty with tubularization of posterior urethra and/or lower bladder for incontinence (eg, Tenago, Leadbetter procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Sling operation for correction of male urinary incontinence (eg, fascia or synthetic)

Service Code
53440 (CPT) Sling operation for correction of male urinary incontinence (eg, fascia or synthetic)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal or revision of sling for male urinary incontinence (eg, fascia or synthetic)

Service Code
53442 (CPT) Removal or revision of sling for male urinary incontinence (eg, fascia or synthetic)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Insertion of tandem cuff (dual cuff)

Service Code
53444 (CPT) Insertion of tandem cuff (dual cuff)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff

Service Code
53445 (CPT) Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required