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

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12465 Results

Transurethral destruction of prostate tissue; by microwave thermotherapy

Service Code
53850 (CPT) Transurethral destruction of prostate tissue; by microwave thermotherapy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Transurethral destruction of prostate tissue; by radiofrequency thermotherapy

Service Code
53852 (CPT) Transurethral destruction of prostate tissue; by radiofrequency thermotherapy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy

Service Code
53854 (CPT) Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Insertion of a temporary prostatic urethral stent, including urethral measurement

Service Code
53855 (CPT) Insertion of a temporary prostatic urethral stent, including urethral measurement
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence

Service Code
53860 (CPT) Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted procedure, urinary system

Service Code
53899 (CPT) Unlisted procedure, urinary system
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

Slitting of prepuce, dorsal or lateral (separate procedure); newborn

Service Code
54000 (CPT) Slitting of prepuce, dorsal or lateral (separate procedure); newborn
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Slitting of prepuce, dorsal or lateral (separate procedure); except newborn

Service Code
54001 (CPT) Slitting of prepuce, dorsal or lateral (separate procedure); except newborn
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Incision and drainage of penis, deep

Service Code
54015 (CPT) Incision and drainage of penis, deep
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

1E-7 Family Planning Services

Service Code
54050 (CPT) Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Family Planning Medicaid services are provided to an eligible Medicaid beneficiary of childbearing age to temporarily or permanently prevent or delay pregnancy. Medicaid Family Planning is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.

Limits

  • • For FP Medicaid beneficiaries, these services are limited to services described in the policy's covered family planning service set.
  • • Outpatient hospital registration is limited for FP Medicaid; the only allowed outpatient registered surgical procedure or service is sterilization, IUD removal, or ultrasound for IUD-related complications including missing strings.
  • • Ultrasound for IUD placement issues may be performed only during an annual assessment, comprehensive preventive medicine evaluation, or inter-periodic visit.
  • • Telehealth claims, when allowed under the policy, must be filed with the provider's usual place of service and not place of service 02.

Exclusions

Ultrasound is not covered to verify IUD placement at the time of insertion. Ultrasounds are not intended for routine checking of placement after IUD insertion. FP Medicaid does not cover medical conditions unrelated to family planning or family planning-related services. For FP Medicaid, surgical procedures or hospital services requiring outpatient beneficiary registration are not covered other than medically necessary contraceptive device removal or sterilizations; the policy note also identifies ultrasound for an IUD complication or removal of an IUD as exceptions to hospital cost responsibility. Hospital emergency room or emergency department services, inpatient hospital services, and treatment for acute or chronic conditions discovered during screening are not covered under FP Medicaid.

Place of Service

Non-Telehealth Claims: a. Inpatient hospitals (not applicable for a FP Medicaid beneficiary) b. Outpatient hospital: For a FP Medicaid beneficiary, the only surgical procedure or service allowed requiring outpatient beneficiary registration is sterilization, IUD removal or ultrasound for IUD related complications including missing strings. c. Office: utilizing offices within places of service 11 (Office), 19 (Off Campus Outpatient) or 22 (On Campus Outpatient) d. Ambulatory Surgical Centers (applicable for a FP Medicaid beneficiary for a sterilization. Numeric POS code(s): 02-Telehealth Provided Other than in Patient's Home.

Additional Service Specifics

FP. GT applies only when the service is telehealth billable and delivered by interactive audio-video.

How to Submit

N/A - No authorization is required

Resources

Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; electrodesiccation

Service Code
54055 (CPT) Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; electrodesiccation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery

Service Code
54056 (CPT) Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery

Service Code
54057 (CPT) Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision

Service Code
54060 (CPT) Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)

Service Code
54065 (CPT) Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Biopsy of penis; (separate procedure)

Service Code
54100 (CPT) Biopsy of penis; (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Biopsy of penis; deep structures

Service Code
54105 (CPT) Biopsy of penis; deep structures
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of penile plaque (Peyronie disease);

Service Code
54110 (CPT) Excision of penile plaque (Peyronie disease);
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of penile plaque (Peyronie disease); with graft to 5 cm in length

Service Code
54111 (CPT) Excision of penile plaque (Peyronie disease); with graft to 5 cm in length
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of penile plaque (Peyronie disease); with graft greater than 5 cm in length

Service Code
54112 (CPT) Excision of penile plaque (Peyronie disease); with graft greater than 5 cm in length
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required