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
Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants
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.
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
Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
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
Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed
How to Submit
N/A - No authorization is required
Unlisted laparoscopy procedure, uterus
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
Unlisted hysteroscopy procedure, uterus
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
Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency
How to Submit
N/A - No authorization is required
Sterilization Procedures
Sterilization means any medical procedure, treatment or an operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged or dysfunctional body part.
Limits
Medicaid shall not cover sterilization:
- a. when the Specific Criteria requirements have not been met; or
- b. for a permanent birth control system by bilateral occlusion of the fallopian
tubes or hysteroscopic tubal sterilization or transcervical sterilization (Essure).
Note: If a judicial court orders a sterilization procedure for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Length of Stay
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Exclusions
Medicaid shall not cover procedures for the reversal of sterilization. Sterilization reversal procedures are reverse bilateral fallopian tube trans-section by means of bilateral salpingoplasty and reversal of a bilateral vasectomy by means of a bilateral vasovasostomy. There is no EPSDT exception to the requirement that the beneficiary be at least 21 years old at the time consent is obtained.If a judicial court orders sterilization for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Additional Service Specifics
Consent is required for all voluntary sterilization. Sterilization consent must be obtained at least 30 and no more than 180 consecutive days before sterilization, except for preterm delivery or emergency abdominal surgery, when at least 72 hours must have passed since consent.
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Other Information
All providers, except ambulatory surgical centers, must append modifier FP to the procedure code when billing for sterilization procedures.
How to Submit
N/A - No authorization is required
Resources
Sterilization Procedures
Sterilization means any medical procedure, treatment or an operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged or dysfunctional body part.
Limits
Medicaid shall not cover sterilization:
- a. when the Specific Criteria requirements have not been met; or
- b. for a permanent birth control system by bilateral occlusion of the fallopian
tubes or hysteroscopic tubal sterilization or transcervical sterilization (Essure).
Note: If a judicial court orders a sterilization procedure for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Length of Stay
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Exclusions
Medicaid shall not cover procedures for the reversal of sterilization. Sterilization reversal procedures are reverse bilateral fallopian tube trans-section by means of bilateral salpingoplasty and reversal of a bilateral vasectomy by means of a bilateral vasovasostomy. There is no EPSDT exception to the requirement that the beneficiary be at least 21 years old at the time consent is obtained.If a judicial court orders sterilization for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Additional Service Specifics
Consent is required for all voluntary sterilization. Sterilization consent must be obtained at least 30 and no more than 180 consecutive days before sterilization, except for preterm delivery or emergency abdominal surgery, when at least 72 hours must have passed since consent.
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Other Information
All providers, except ambulatory surgical centers, must append modifier FP to the procedure code when billing for sterilization procedures.
How to Submit
N/A - No authorization is required
Resources
Sterilization Procedures
Sterilization means any medical procedure, treatment or an operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged or dysfunctional body part.
Limits
Medicaid shall not cover sterilization:
- a. when the Specific Criteria requirements have not been met; or
- b. for a permanent birth control system by bilateral occlusion of the fallopian
tubes or hysteroscopic tubal sterilization or transcervical sterilization (Essure).
Note: If a judicial court orders a sterilization procedure for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Length of Stay
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Exclusions
Medicaid shall not cover procedures for the reversal of sterilization. Sterilization reversal procedures are reverse bilateral fallopian tube trans-section by means of bilateral salpingoplasty and reversal of a bilateral vasectomy by means of a bilateral vasovasostomy. There is no EPSDT exception to the requirement that the beneficiary be at least 21 years old at the time consent is obtained.If a judicial court orders sterilization for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Additional Service Specifics
Consent is required for all voluntary sterilization. Sterilization consent must be obtained at least 30 and no more than 180 consecutive days before sterilization, except for preterm delivery or emergency abdominal surgery, when at least 72 hours must have passed since consent.
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Other Information
All providers, except ambulatory surgical centers, must append modifier FP to the procedure code when billing for sterilization procedures.
How to Submit
N/A - No authorization is required
Resources
Sterilization Procedures
Sterilization means any medical procedure, treatment or an operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged or dysfunctional body part.
Limits
Medicaid shall not cover sterilization:
- a. when the Specific Criteria requirements have not been met; or
- b. for a permanent birth control system by bilateral occlusion of the fallopian
tubes or hysteroscopic tubal sterilization or transcervical sterilization (Essure).
Note: If a judicial court orders a sterilization procedure for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Length of Stay
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Exclusions
Medicaid shall not cover procedures for the reversal of sterilization. Sterilization reversal procedures are reverse bilateral fallopian tube trans-section by means of bilateral salpingoplasty and reversal of a bilateral vasectomy by means of a bilateral vasovasostomy. There is no EPSDT exception to the requirement that the beneficiary be at least 21 years old at the time consent is obtained.If a judicial court orders sterilization for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Additional Service Specifics
Consent is required for all voluntary sterilization. Sterilization consent must be obtained at least 30 and no more than 180 consecutive days before sterilization, except for preterm delivery or emergency abdominal surgery, when at least 72 hours must have passed since consent.
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Other Information
All providers, except ambulatory surgical centers, must append modifier FP to the procedure code when billing for sterilization procedures.
How to Submit
N/A - No authorization is required
Resources
Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure)
How to Submit
N/A - No authorization is required
Sterilization Procedures
Sterilization means any medical procedure, treatment or an operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged or dysfunctional body part.
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
Medicaid shall not cover sterilization:
- a. when the Specific Criteria requirements have not been met; or
- b. for a permanent birth control system by bilateral occlusion of the fallopian
tubes or hysteroscopic tubal sterilization or transcervical sterilization (Essure).
Note: If a judicial court orders a sterilization procedure for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Length of Stay
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Exclusions
Medicaid shall not cover procedures for the reversal of sterilization. Sterilization reversal procedures are reverse bilateral fallopian tube trans-section by means of bilateral salpingoplasty and reversal of a bilateral vasectomy by means of a bilateral vasovasostomy. There is no EPSDT exception to the requirement that the beneficiary be at least 21 years old at the time consent is obtained.If a judicial court orders sterilization for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Additional Service Specifics
Consent is required for all voluntary sterilization. Sterilization consent must be obtained at least 30 and no more than 180 consecutive days before sterilization, except for preterm delivery or emergency abdominal surgery, when at least 72 hours must have passed since consent.
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Other Information
All providers, except ambulatory surgical centers, must append modifier FP to the procedure code when billing for sterilization procedures.
How to Submit
N/A - No authorization is required
Resources
Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
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
Sterilization Procedures
Sterilization means any medical procedure, treatment or an operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged or dysfunctional body part.
Limits
Medicaid shall not cover sterilization:
- a. when the Specific Criteria requirements have not been met; or
- b. for a permanent birth control system by bilateral occlusion of the fallopian
tubes or hysteroscopic tubal sterilization or transcervical sterilization (Essure).
Note: If a judicial court orders a sterilization procedure for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Length of Stay
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Exclusions
Medicaid shall not cover procedures for the reversal of sterilization. Sterilization reversal procedures are reverse bilateral fallopian tube trans-section by means of bilateral salpingoplasty and reversal of a bilateral vasectomy by means of a bilateral vasovasostomy. There is no EPSDT exception to the requirement that the beneficiary be at least 21 years old at the time consent is obtained.If a judicial court orders sterilization for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Additional Service Specifics
Consent is required for all voluntary sterilization. Sterilization consent must be obtained at least 30 and no more than 180 consecutive days before sterilization, except for preterm delivery or emergency abdominal surgery, when at least 72 hours must have passed since consent.
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Other Information
All providers, except ambulatory surgical centers, must append modifier FP to the procedure code when billing for sterilization procedures.
How to Submit
N/A - No authorization is required
Resources
Sterilization Procedures
Sterilization means any medical procedure, treatment or an operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged or dysfunctional body part.
Limits
Medicaid shall not cover sterilization:
- a. when the Specific Criteria requirements have not been met; or
- b. for a permanent birth control system by bilateral occlusion of the fallopian
tubes or hysteroscopic tubal sterilization or transcervical sterilization (Essure).
Note: If a judicial court orders a sterilization procedure for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Length of Stay
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Exclusions
Medicaid shall not cover procedures for the reversal of sterilization. Sterilization reversal procedures are reverse bilateral fallopian tube trans-section by means of bilateral salpingoplasty and reversal of a bilateral vasectomy by means of a bilateral vasovasostomy. There is no EPSDT exception to the requirement that the beneficiary be at least 21 years old at the time consent is obtained.If a judicial court orders sterilization for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.
Additional Service Specifics
Consent is required for all voluntary sterilization. Sterilization consent must be obtained at least 30 and no more than 180 consecutive days before sterilization, except for preterm delivery or emergency abdominal surgery, when at least 72 hours must have passed since consent.
Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.
Other Information
All providers, except ambulatory surgical centers, must append modifier FP to the procedure code when billing for sterilization procedures.
How to Submit
N/A - No authorization is required
Resources
Laparoscopy, surgical; with fimbrioplasty
How to Submit
N/A - No authorization is required
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