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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

Exploration of epididymis, with or without biopsy

Service Code
54865 (CPT) Exploration of epididymis, with or without biopsy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral

Service Code
54900 (CPT) Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral

Service Code
54901 (CPT) Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication

Service Code
55000 (CPT) Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of hydrocele; unilateral

Service Code
55040 (CPT) Excision of hydrocele; unilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of hydrocele; bilateral

Service Code
55041 (CPT) Excision of hydrocele; bilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair of tunica vaginalis hydrocele (Bottle type)

Service Code
55060 (CPT) Repair of tunica vaginalis hydrocele (Bottle type)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Drainage of scrotal wall abscess

Service Code
55100 (CPT) Drainage of scrotal wall abscess
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Scrotal exploration

Service Code
55110 (CPT) Scrotal exploration
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal of foreign body in scrotum

Service Code
55120 (CPT) Removal of foreign body in scrotum
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Resection of scrotum

Service Code
55150 (CPT) Resection of scrotum
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Scrotoplasty; simple

Service Code
55175 (CPT) Scrotoplasty; simple
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.

Scrotoplasty; complicated

Service Code
55180 (CPT) Scrotoplasty; complicated
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.

Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure)

Service Code
55200 (CPT) Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Sterilization Procedures

Service Code
55250 (CPT) Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
Medicaid Adult (Age 21+)
Diagnosis Group
Physical Health

Sterilization means any medical procedure, treatment or an operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged or dysfunctional body part.

Limits

Medicaid shall not cover sterilization:

  • a. when the Specific Criteria requirements have not been met; or
  • b. for a permanent birth control system by bilateral occlusion of the fallopian

tubes or hysteroscopic tubal sterilization or transcervical sterilization (Essure).

Note: If a judicial court orders a sterilization procedure for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.

Length of Stay

Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.

Exclusions

Medicaid shall not cover procedures for the reversal of sterilization. Sterilization reversal procedures are reverse bilateral fallopian tube trans-section by means of bilateral salpingoplasty and reversal of a bilateral vasectomy by means of a bilateral vasovasostomy. There is no EPSDT exception to the requirement that the beneficiary be at least 21 years old at the time consent is obtained.If a judicial court orders sterilization for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.

Additional Service Specifics

Consent is required for all voluntary sterilization. Sterilization consent must be obtained at least 30 and no more than 180 consecutive days before sterilization, except for preterm delivery or emergency abdominal surgery, when at least 72 hours must have passed since consent.

Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.

Other Information

All providers, except ambulatory surgical centers, must append modifier FP to the procedure code when billing for sterilization procedures.

How to Submit

N/A - No authorization is required

Resources

Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral

Service Code
55300 (CPT) Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Vasovasostomy, vasovasorrhaphy

Service Code
55400 (CPT) Vasovasostomy, vasovasorrhaphy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of hydrocele of spermatic cord, unilateral (separate procedure)

Service Code
55500 (CPT) Excision of hydrocele of spermatic cord, unilateral (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of lesion of spermatic cord (separate procedure)

Service Code
55520 (CPT) Excision of lesion of spermatic cord (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure)

Service Code
55530 (CPT) Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required