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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

Removal foreign body from deep penile tissue (eg, plastic implant)

Service Code
54115 (CPT) Removal foreign body from deep penile tissue (eg, plastic implant)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Amputation of penis; partial

Service Code
54120 (CPT) Amputation of penis; partial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Amputation of penis; complete

Service Code
54125 (CPT) Amputation of penis; complete
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.

Amputation of penis, radical; with bilateral inguinofemoral lymphadenectomy

Service Code
54130 (CPT) Amputation of penis, radical; with bilateral inguinofemoral lymphadenectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Amputation of penis, radical; in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes

Service Code
54135 (CPT) Amputation of penis, radical; in continuity 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

Medically Necessary Circumcision

Service Code
54150 (CPT) Circumcision, using clamp or other device with regional dorsal penile or ring block
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Male circumcision is the surgical removal of the foreskin (prepuce), which is the layer of skin covering the head (glans) of the penis. The foreskin provides sensation and lubrication for the penis. After the foreskin is removed, it can't be put back on again.

Limits

Newborn circumcision applies to a healthy newborn age 28 days or less and may be performed while the baby is in the hospital or in an office setting.

Non-newborn circumcision applies beyond the newborn period, meaning greater than 28 days of age.

Circumcision is covered only once per lifetime when medically necessary

Exclusions

When repair of incomplete circumcision is performed as a post-circumcision procedure, the date of the original circumcision must be noted in the health record.

Place of Service

Inpatient, Outpatient, Ambulatory Surgery Center, and Office.

How to Submit

N/A - No authorization is required

Resources

Medically Necessary Circumcision

Service Code
54160 (CPT) Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Male circumcision is the surgical removal of the foreskin (prepuce), which is the layer of skin covering the head (glans) of the penis. The foreskin provides sensation and lubrication for the penis. After the foreskin is removed, it can't be put back on again.

Limits

Newborn circumcision applies to a healthy newborn age 28 days or less and may be performed while the baby is in the hospital or in an office setting.

Non-newborn circumcision applies beyond the newborn period, meaning greater than 28 days of age.

Circumcision is covered only once per lifetime when medically necessary

Exclusions

When repair of incomplete circumcision is performed as a post-circumcision procedure, the date of the original circumcision must be noted in the health record.

Place of Service

Inpatient, Outpatient, Ambulatory Surgery Center, and Office.

How to Submit

N/A - No authorization is required

Resources

Medically Necessary Circumcision

Service Code
54161 (CPT) Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Male circumcision is the surgical removal of the foreskin (prepuce), which is the layer of skin covering the head (glans) of the penis. The foreskin provides sensation and lubrication for the penis. After the foreskin is removed, it can't be put back on again.

Limits

Newborn circumcision applies to a healthy newborn age 28 days or less and may be performed while the baby is in the hospital or in an office setting.

Non-newborn circumcision applies beyond the newborn period, meaning greater than 28 days of age.

Circumcision is covered only once per lifetime when medically necessary

Exclusions

When repair of incomplete circumcision is performed as a post-circumcision procedure, the date of the original circumcision must be noted in the health record.

Place of Service

Inpatient, Outpatient, Ambulatory Surgery Center, and Office.

How to Submit

N/A - No authorization is required

Resources

Medically Necessary Circumcision

Service Code
54162 (CPT) Lysis or excision of penile post-circumcision adhesions
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Male circumcision is the surgical removal of the foreskin (prepuce), which is the layer of skin covering the head (glans) of the penis. The foreskin provides sensation and lubrication for the penis. After the foreskin is removed, it can't be put back on again.

Limits

Newborn circumcision applies to a healthy newborn age 28 days or less and may be performed while the baby is in the hospital or in an office setting.

Non-newborn circumcision applies beyond the newborn period, meaning greater than 28 days of age.

Circumcision is covered only once per lifetime when medically necessary

Exclusions

When repair of incomplete circumcision is performed as a post-circumcision procedure, the date of the original circumcision must be noted in the health record.

Place of Service

Inpatient, Outpatient, Ambulatory Surgery Center, and Office.

How to Submit

N/A - No authorization is required

Resources

Medically Necessary Circumcision

Service Code
54163 (CPT) Repair incomplete circumcision
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Male circumcision is the surgical removal of the foreskin (prepuce), which is the layer of skin covering the head (glans) of the penis. The foreskin provides sensation and lubrication for the penis. After the foreskin is removed, it can't be put back on again.

Limits

Newborn circumcision applies to a healthy newborn age 28 days or less and may be performed while the baby is in the hospital or in an office setting.

Non-newborn circumcision applies beyond the newborn period, meaning greater than 28 days of age.

Circumcision is covered only once per lifetime when medically necessary

Exclusions

When repair of incomplete circumcision is performed as a post-circumcision procedure, the date of the original circumcision must be noted in the health record.

Place of Service

Inpatient, Outpatient, Ambulatory Surgery Center, and Office.

How to Submit

N/A - No authorization is required

Resources

Frenulotomy of penis

Service Code
54164 (CPT) Frenulotomy of penis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Injection procedure for Peyronie disease;

Service Code
54200 (CPT) Injection procedure for Peyronie disease;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Injection procedure for Peyronie disease; with surgical exposure of plaque

Service Code
54205 (CPT) Injection procedure for Peyronie disease; with surgical exposure of plaque
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Irrigation of corpora cavernosa for priapism

Service Code
54220 (CPT) Irrigation of corpora cavernosa for priapism
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Injection procedure for corpora cavernosography

Service Code
54230 (CPT) Injection procedure for corpora cavernosography
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Dynamic cavernosometry, including intracavernosal injection of vasoactive drugs (eg, papaverine, phentolamine)

Service Code
54231 (CPT) Dynamic cavernosometry, including intracavernosal injection of vasoactive drugs (eg, papaverine, phentolamine)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine)

Service Code
54235 (CPT) Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Penile plethysmography

Service Code
54240 (CPT) Penile plethysmography
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Nocturnal penile tumescence and/or rigidity test

Service Code
54250 (CPT) Nocturnal penile tumescence and/or rigidity test
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra

Service Code
54300 (CPT) Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required