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
Hysteroplasty, repair of uterine anomaly (Strassman type)
How to Submit
N/A - No authorization is required
Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less;
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.
Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
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.
Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g;
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.
Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
How to Submit
N/A - No authorization is required
Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas
How to Submit
N/A - No authorization is required
Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g
How to Submit
N/A - No authorization is required
1E-1, Hysterectomy
Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.
Limits
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.
Length of Stay
Covered once in a lifetime per individual
Exclusions
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.
Diagnosis Requirements
Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.
Place of Service
Inpatient hospital, Outpatient hospital.
How to Submit
N/A - No authorization is required
Resources
Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less
Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
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.
Limits
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.
Length of Stay
Covered once in a lifetime per individual
Exclusions
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.
Diagnosis Requirements
Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.
Place of Service
Inpatient hospital, Outpatient hospital.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-1, Hysterectomy
Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Conditional Requirements
Prior authorization may be required. Check North Carolina clinical coverage policy 1S-10, Genetic Testing for Carrier and Prenatal for more information
Limits
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.
Length of Stay
Covered once in a lifetime per individual
Exclusions
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.
Diagnosis Requirements
Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.
Place of Service
Inpatient hospital, Outpatient hospital.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-1, Hysterectomy
Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Conditional Requirements
Prior authorization may be required. Check North Carolina clinical coverage policy 1S-10, Genetic Testing for Carrier and Prenatal for more information
Limits
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.
Length of Stay
Covered once in a lifetime per individual
Exclusions
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.
Diagnosis Requirements
Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.
Place of Service
Inpatient hospital, Outpatient hospital.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-1, Hysterectomy
Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Conditional Requirements
Prior authorization may be required. Check North Carolina clinical coverage policy 1S-10, Genetic Testing for Carrier and Prenatal for more information
Limits
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.
Length of Stay
Covered once in a lifetime per individual
Exclusions
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.
Diagnosis Requirements
Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.
Place of Service
Inpatient hospital, Outpatient hospital.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-1, Hysterectomy
Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.
Authorization Guidelines
Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Conditional Requirements
Prior authorization may be required. Check North Carolina clinical coverage policy 1S-10, Genetic Testing for Carrier and Prenatal for more information
Limits
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.
Length of Stay
Covered once in a lifetime per individual
Exclusions
Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.
Diagnosis Requirements
Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.
Place of Service
Inpatient hospital, Outpatient hospital.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
Hysteroscopy, diagnostic (separate procedure)
How to Submit
N/A - No authorization is required
Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C
How to Submit
N/A - No authorization is required
Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)
How to Submit
N/A - No authorization is required
Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)
How to Submit
N/A - No authorization is required
Hysteroscopy, surgical; with removal of leiomyomata
How to Submit
N/A - No authorization is required
Hysteroscopy, surgical; with removal of impacted foreign body
How to Submit
N/A - No authorization is required
Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)
How to Submit
N/A - No authorization is required
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.