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
Closure of rectovaginal fistula; transperineal approach, with perineal body reconstruction, with or without levator plication
Service Code
57308 (CPT) Closure of rectovaginal fistula; transperineal approach, with perineal body reconstruction, with or without levator plication
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of urethrovaginal fistula;
Service Code
57310 (CPT) Closure of urethrovaginal fistula;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of urethrovaginal fistula; with bulbocavernosus transplant
Service Code
57311 (CPT) Closure of urethrovaginal fistula; with bulbocavernosus transplant
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of vesicovaginal fistula; vaginal approach
Service Code
57320 (CPT) Closure of vesicovaginal fistula; vaginal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of vesicovaginal fistula; transvesical and vaginal approach
Service Code
57330 (CPT) Closure of vesicovaginal fistula; transvesical and vaginal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vaginoplasty for intersex state
Service Code
57335 (CPT) Vaginoplasty for intersex state
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.
Dilation of vagina under anesthesia (other than local)
Service Code
57400 (CPT) Dilation of vagina under anesthesia (other than local)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Pelvic examination under anesthesia (other than local)
Service Code
57410 (CPT) Pelvic examination under anesthesia (other than local)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Removal of impacted vaginal foreign body (separate procedure) under anesthesia (other than local)
Service Code
57415 (CPT) Removal of impacted vaginal foreign body (separate procedure) under anesthesia (other than local)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colposcopy of the entire vagina, with cervix if present;
Service Code
57420 (CPT) Colposcopy of the entire vagina, with cervix if present;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix
Service Code
57421 (CPT) Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix
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), laparoscopic approach
Service Code
57423 (CPT) Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Laparoscopy, surgical, colpopexy (suspension of vaginal apex)
Service Code
57425 (CPT) Laparoscopy, surgical, colpopexy (suspension of vaginal apex)
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, laparoscopic approach
Service Code
57426 (CPT) Revision (including removal) of prosthetic vaginal graft, laparoscopic approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colposcopy of the cervix including upper/adjacent vagina;
Service Code
57452 (CPT) Colposcopy of the cervix including upper/adjacent vagina;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage
Service Code
57454 (CPT) Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix
Service Code
57455 (CPT) Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage
Service Code
57456 (CPT) Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix
Service Code
57460 (CPT) Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix
Service Code
57461 (CPT) Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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