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

Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy

Service Code
55875 (CPT) Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple

Service Code
55876 (CPT) Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted procedure, male genital system

Service Code
55899 (CPT) Unlisted procedure, male genital 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

Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application

Service Code
55920 (CPT) Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Intersex surgery; male to female

Service Code
55970 (CPT) Intersex surgery; male to female
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

Intersex surgery; female to male

Service Code
55980 (CPT) Intersex surgery; female to male
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 vulva or perineal abscess

Service Code
56405 (CPT) Incision and drainage of vulva or perineal abscess
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Incision and drainage of Bartholin's gland abscess

Service Code
56420 (CPT) Incision and drainage of Bartholin's gland abscess
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Marsupialization of Bartholin's gland cyst

Service Code
56440 (CPT) Marsupialization of Bartholin's gland cyst
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Lysis of labial adhesions

Service Code
56441 (CPT) Lysis of labial adhesions
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Hymenotomy, simple incision

Service Code
56442 (CPT) Hymenotomy, simple incision
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
56501 (CPT) Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
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), vulva; extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)

Service Code
56515 (CPT) Destruction of lesion(s), vulva; 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 vulva or perineum (separate procedure); 1 lesion

Service Code
56605 (CPT) Biopsy of vulva or perineum (separate procedure); 1 lesion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Biopsy of vulva or perineum (separate procedure); each separate additional lesion (List separately in addition to code for primary procedure)

Service Code
56606 (CPT) Biopsy of vulva or perineum (separate procedure); each separate additional lesion (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Vulvectomy simple; partial

Service Code
56620 (CPT) Vulvectomy simple; partial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Vulvectomy simple; complete

Service Code
56625 (CPT) Vulvectomy simple; 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.

Vulvectomy, radical, partial;

Service Code
56630 (CPT) Vulvectomy, radical, partial;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy

Service Code
56631 (CPT) Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Vulvectomy, radical, partial; with bilateral inguinofemoral lymphadenectomy

Service Code
56632 (CPT) Vulvectomy, radical, partial; with bilateral inguinofemoral lymphadenectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required