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

Insertion of penile prosthesis; inflatable (self-contained)

Service Code
54401 (CPT) Insertion of penile prosthesis; inflatable (self-contained)
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.

Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir

Service Code
54405 (CPT) Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir
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

Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis

Service Code
54406 (CPT) Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis
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

Repair of component(s) of a multi-component, inflatable penile prosthesis

Service Code
54408 (CPT) Repair of component(s) of a multi-component, inflatable penile prosthesis
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

Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session

Service Code
54410 (CPT) Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session
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

Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue

Service Code
54411 (CPT) Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue
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

Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis

Service Code
54415 (CPT) Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis
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

Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session

Service Code
54416 (CPT) Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session
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

Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue

Service Code
54417 (CPT) Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis 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

Corpora cavernosa-saphenous vein shunt (priapism operation), unilateral or bilateral

Service Code
54420 (CPT) Corpora cavernosa-saphenous vein shunt (priapism operation), unilateral or bilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Corpora cavernosa-corpus spongiosum shunt (priapism operation), unilateral or bilateral

Service Code
54430 (CPT) Corpora cavernosa-corpus spongiosum shunt (priapism operation), unilateral or bilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter procedure, rongeur, or punch) for priapism

Service Code
54435 (CPT) Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter procedure, rongeur, or punch) for priapism
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair of traumatic corporeal tear(s)

Service Code
54437 (CPT) Repair of traumatic corporeal tear(s)
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 injury

Service Code
54440 (CPT) Plastic operation of penis for injury
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
54450 (CPT) Foreskin manipulation including lysis of preputial adhesions and stretching
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

Biopsy of testis, needle (separate procedure)

Service Code
54500 (CPT) Biopsy of testis, needle (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Biopsy of testis, incisional (separate procedure)

Service Code
54505 (CPT) Biopsy of testis, incisional (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of extraparenchymal lesion of testis

Service Code
54512 (CPT) Excision of extraparenchymal lesion of testis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach

Service Code
54520 (CPT) Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach
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.

Orchiectomy, partial

Service Code
54522 (CPT) Orchiectomy, partial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required