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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

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12465 Results

Laparoscopy, surgical; with salpingostomy (salpingoneostomy)

Service Code
58673 (CPT) Laparoscopy, surgical; with salpingostomy (salpingoneostomy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency

Service Code
58674 (CPT) Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted laparoscopy procedure, oviduct, ovary

Service Code
58679 (CPT) Unlisted laparoscopy procedure, oviduct, ovary
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.

How to Submit

Please submit your request to Trillium Health Resources

Sterilization Procedures

Service Code
58700 (CPT) Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
Medicaid Adult (Age 21+)
Diagnosis Group
Physical Health

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

Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)

Service Code
58720 (CPT) Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)
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.

Lysis of adhesions (salpingolysis, ovariolysis)

Service Code
58740 (CPT) Lysis of adhesions (salpingolysis, ovariolysis)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tubotubal anastomosis

Service Code
58750 (CPT) Tubotubal anastomosis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tubouterine implantation

Service Code
58752 (CPT) Tubouterine implantation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Fimbrioplasty

Service Code
58760 (CPT) Fimbrioplasty
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Salpingostomy (salpingoneostomy)

Service Code
58770 (CPT) Salpingostomy (salpingoneostomy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach

Service Code
58800 (CPT) Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); abdominal approach

Service Code
58805 (CPT) Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); abdominal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Drainage of ovarian abscess; vaginal approach, open

Service Code
58820 (CPT) Drainage of ovarian abscess; vaginal approach, open
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Drainage of ovarian abscess; abdominal approach

Service Code
58822 (CPT) Drainage of ovarian abscess; abdominal approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Transposition, ovary(s)

Service Code
58825 (CPT) Transposition, ovary(s)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Biopsy of ovary, unilateral or bilateral (separate procedure)

Service Code
58900 (CPT) Biopsy of ovary, unilateral or bilateral (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Wedge resection or bisection of ovary, unilateral or bilateral

Service Code
58920 (CPT) Wedge resection or bisection of ovary, unilateral or bilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Ovarian cystectomy, unilateral or bilateral

Service Code
58925 (CPT) Ovarian cystectomy, unilateral or bilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Oophorectomy, partial or total, unilateral or bilateral;

Service Code
58940 (CPT) Oophorectomy, partial or total, unilateral or bilateral;
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.

Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingecto

Service Code
58943 (CPT) Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingecto
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required