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
12465 Results
Vaginectomy, partial removal of vaginal wall;
Service Code
57106 (CPT) Vaginectomy, partial removal of vaginal wall;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy)
Service Code
57107 (CPT) Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy)
Service Code
57109 (CPT) Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vaginectomy, complete removal of vaginal wall;
Service Code
57110 (CPT) Vaginectomy, complete removal of vaginal wall;
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.
Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy)
Service Code
57111 (CPT) Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colpocleisis (Le Fort type)
Service Code
57120 (CPT) Colpocleisis (Le Fort type)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of vaginal septum
Service Code
57130 (CPT) Excision of vaginal septum
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of vaginal cyst or tumor
Service Code
57135 (CPT) Excision of vaginal cyst or tumor
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease
Service Code
57150 (CPT) Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy
Service Code
57155 (CPT) Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy
Service Code
57156 (CPT) Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Fitting and insertion of pessary or other intravaginal support device
Service Code
57160 (CPT) Fitting and insertion of pessary or other intravaginal support device
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Diaphragm or cervical cap fitting with instructions
Service Code
57170 (CPT) Diaphragm or cervical cap fitting with instructions
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Introduction of any hemostatic agent or pack for spontaneous or traumatic nonobstetrical vaginal hemorrhage (separate procedure)
Service Code
57180 (CPT) Introduction of any hemostatic agent or pack for spontaneous or traumatic nonobstetrical vaginal hemorrhage (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colporrhaphy, suture of injury of vagina (nonobstetrical)
Service Code
57200 (CPT) Colporrhaphy, suture of injury of vagina (nonobstetrical)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colpoperineorrhaphy, suture of injury of vagina and/or perineum (nonobstetrical)
Service Code
57210 (CPT) Colpoperineorrhaphy, suture of injury of vagina and/or perineum (nonobstetrical)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Plastic operation on urethral sphincter, vaginal approach (eg, Kelly urethral plication)
Service Code
57220 (CPT) Plastic operation on urethral sphincter, vaginal approach (eg, Kelly urethral plication)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Plastic repair of urethrocele
Service Code
57230 (CPT) Plastic repair of urethrocele
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when performed
Service Code
57240 (CPT) Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when performed
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy
Service Code
57250 (CPT) Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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