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

Orchiectomy, radical, for tumor; inguinal approach

Service Code
54530 (CPT) Orchiectomy, radical, for tumor; inguinal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Orchiectomy, radical, for tumor; with abdominal exploration

Service Code
54535 (CPT) Orchiectomy, radical, for tumor; with abdominal exploration
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Exploration for undescended testis (inguinal or scrotal area)

Service Code
54550 (CPT) Exploration for undescended testis (inguinal or scrotal area)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Exploration for undescended testis with abdominal exploration

Service Code
54560 (CPT) Exploration for undescended testis with abdominal exploration
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Reduction of torsion of testis, surgical, with or without fixation of contralateral testis

Service Code
54600 (CPT) Reduction of torsion of testis, surgical, with or without fixation of contralateral testis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Fixation of contralateral testis (separate procedure)

Service Code
54620 (CPT) Fixation of contralateral testis (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Orchiopexy, inguinal or scrotal approach

Service Code
54640 (CPT) Orchiopexy, inguinal or scrotal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Orchiopexy, abdominal approach, for intra-abdominal testis (eg, Fowler-Stephens)

Service Code
54650 (CPT) Orchiopexy, abdominal approach, for intra-abdominal testis (eg, Fowler-Stephens)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Insertion of testicular prosthesis (separate procedure)

Service Code
54660 (CPT) Insertion of testicular prosthesis (separate 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.

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.

Suture or repair of testicular injury

Service Code
54670 (CPT) Suture or repair of testicular injury
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Transplantation of testis(es) to thigh (because of scrotal destruction)

Service Code
54680 (CPT) Transplantation of testis(es) to thigh (because of scrotal destruction)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Laparoscopy, surgical; orchiectomy

Service Code
54690 (CPT) Laparoscopy, surgical; orchiectomy
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.

Laparoscopy, surgical; orchiopexy for intra-abdominal testis

Service Code
54692 (CPT) Laparoscopy, surgical; orchiopexy for intra-abdominal testis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted laparoscopy procedure, testis

Service Code
54699 (CPT) Unlisted laparoscopy procedure, testis
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

Incision and drainage of epididymis, testis and/or scrotal space (eg, abscess or hematoma)

Service Code
54700 (CPT) Incision and drainage of epididymis, testis and/or scrotal space (eg, abscess or hematoma)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Biopsy of epididymis, needle

Service Code
54800 (CPT) Biopsy of epididymis, needle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of local lesion of epididymis

Service Code
54830 (CPT) Excision of local lesion of epididymis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of spermatocele, with or without epididymectomy

Service Code
54840 (CPT) Excision of spermatocele, with or without epididymectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Epididymectomy; unilateral

Service Code
54860 (CPT) Epididymectomy; unilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Epididymectomy; bilateral

Service Code
54861 (CPT) Epididymectomy; bilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required