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
Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff
Service Code
53446 (CPT) Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session
Service Code
53447 (CPT) Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session including irrigation and debridement of infected tissue
Service Code
53448 (CPT) Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session including irrigation and debridement of infected tissue
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff
Service Code
53449 (CPT) Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Urethromeatoplasty, with mucosal advancement
Service Code
53450 (CPT) Urethromeatoplasty, with mucosal advancement
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type procedure)
Service Code
53460 (CPT) Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type procedure)
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
Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical obstruction, scarring)
Service Code
53500 (CPT) Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical obstruction, scarring)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Urethrorrhaphy, suture of urethral wound or injury, female
Service Code
53502 (CPT) Urethrorrhaphy, suture of urethral wound or injury, female
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Urethrorrhaphy, suture of urethral wound or injury; penile
Service Code
53505 (CPT) Urethrorrhaphy, suture of urethral wound or injury; penile
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Urethrorrhaphy, suture of urethral wound or injury; perineal
Service Code
53510 (CPT) Urethrorrhaphy, suture of urethral wound or injury; perineal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Urethrorrhaphy, suture of urethral wound or injury; prostatomembranous
Service Code
53515 (CPT) Urethrorrhaphy, suture of urethral wound or injury; prostatomembranous
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of urethrostomy or urethrocutaneous fistula, male (separate procedure)
Service Code
53520 (CPT) Closure of urethrostomy or urethrocutaneous fistula, male (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Dilation of urethral stricture by passage of sound or urethral dilator, male; initial
Service Code
53600 (CPT) Dilation of urethral stricture by passage of sound or urethral dilator, male; initial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Dilation of urethral stricture by passage of sound or urethral dilator, male; subsequent
Service Code
53601 (CPT) Dilation of urethral stricture by passage of sound or urethral dilator, male; subsequent
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, general or conduction (spinal) anesthesia
Service Code
53605 (CPT) Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, general or conduction (spinal) anesthesia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Dilation of urethral stricture by passage of filiform and follower, male; initial
Service Code
53620 (CPT) Dilation of urethral stricture by passage of filiform and follower, male; initial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Dilation of urethral stricture by passage of filiform and follower, male; subsequent
Service Code
53621 (CPT) Dilation of urethral stricture by passage of filiform and follower, male; subsequent
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Dilation of female urethra including suppository and/or instillation; initial
Service Code
53660 (CPT) Dilation of female urethra including suppository and/or instillation; initial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Dilation of female urethra including suppository and/or instillation; subsequent
Service Code
53661 (CPT) Dilation of female urethra including suppository and/or instillation; subsequent
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Dilation of female urethra, general or conduction (spinal) anesthesia
Service Code
53665 (CPT) Dilation of female urethra, general or conduction (spinal) anesthesia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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