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
Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed;
Service Code
57260 (CPT) Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed; with enterocele repair
Service Code
57265 (CPT) Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed; with enterocele repair
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure)
Service Code
57267 (CPT) Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (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
Repair of enterocele, vaginal approach (separate procedure)
Service Code
57268 (CPT) Repair of enterocele, vaginal approach (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of enterocele, abdominal approach (separate procedure)
Service Code
57270 (CPT) Repair of enterocele, abdominal approach (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colpopexy, abdominal approach
Service Code
57280 (CPT) Colpopexy, abdominal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus)
Service Code
57282 (CPT) Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy)
Service Code
57283 (CPT) Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach
Service Code
57284 (CPT) Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach
Service Code
57285 (CPT) Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Removal or revision of sling for stress incontinence (eg, fascia or synthetic)
Service Code
57287 (CPT) Removal or revision of sling for stress incontinence (eg, fascia or synthetic)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sling operation for stress incontinence (eg, fascia or synthetic)
Service Code
57288 (CPT) Sling operation for stress incontinence (eg, fascia or synthetic)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Pereyra procedure, including anterior colporrhaphy
Service Code
57289 (CPT) Pereyra procedure, including anterior colporrhaphy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Construction of artificial vagina; without graft
Service Code
57291 (CPT) Construction of artificial vagina; without graft
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Construction of artificial vagina; with graft
Service Code
57292 (CPT) Construction of artificial vagina; with graft
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.
Revision (including removal) of prosthetic vaginal graft; vaginal approach
Service Code
57295 (CPT) Revision (including removal) of prosthetic vaginal graft; vaginal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Revision (including removal) of prosthetic vaginal graft; open abdominal approach
Service Code
57296 (CPT) Revision (including removal) of prosthetic vaginal graft; open abdominal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of rectovaginal fistula; vaginal or transanal approach
Service Code
57300 (CPT) Closure of rectovaginal fistula; vaginal or transanal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of rectovaginal fistula; abdominal approach
Service Code
57305 (CPT) Closure of rectovaginal fistula; abdominal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of rectovaginal fistula; abdominal approach, with concomitant colostomy
Service Code
57307 (CPT) Closure of rectovaginal fistula; abdominal approach, with concomitant colostomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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