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
Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy;
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
Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (ie, radical excision or destruction, intra-abdominal or retroperitoneal tumors)
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
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
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
Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy
How to Submit
N/A - No authorization is required
Laparotomy, for staging or restaging of ovarian, tubal, or primary peritoneal malignancy (second look), with or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aorti
How to Submit
N/A - No authorization is required
Follicle puncture for oocyte retrieval, any method
How to Submit
N/A - No authorization is required
Embryo transfer, intrauterine
How to Submit
N/A - No authorization is required
Gamete, zygote, or embryo intrafallopian transfer, any method
How to Submit
N/A - No authorization is required
Unlisted procedure, female genital system (nonobstetrical)
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
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Limits
Generally performed at or beyond 14 weeks gestation for genetic testing.
Other procedures performed on the same date of service as amniocentesis are covered if performed by the same provider and billed according to modifier rules.
Other related procedures during the amniocentesis follow-up period, and unrelated procedures during that follow-up period, are covered if performed by the provider who performed the amniocentesis. Amniocentesis is not covered when performed for sex determination without documented risk of an X-linked disorder, or for routine screening without the risk factors listed in the amniocentesis coverage subsection.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
N/A - No authorization is required
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Limits
Generally performed at or beyond 14 weeks gestation for genetic testing.
Other procedures performed on the same date of service as amniocentesis are covered if performed by the same provider and billed according to modifier rules.
Other related procedures during the amniocentesis follow-up period, and unrelated procedures during that follow-up period, are covered if performed by the provider who performed the amniocentesis. Amniocentesis is not covered when performed for sex determination without documented risk of an X-linked disorder, or for routine screening without the risk factors listed in the amniocentesis coverage subsection.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
N/A - No authorization is required
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
N/A - No authorization is required
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Limits
Chorionic villus sampling is performed during pregnancy at 10 to 12 weeks.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
N/A - No authorization is required
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Limits
Chorionic villus sampling is performed during pregnancy at 10 to 12 weeks.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
N/A - No authorization is required
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Limits
Fetal oxytocin stress testing cannot be billed on the same date of service as labor room delivery (RC720)
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
N/A - No authorization is required
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Limits
Up to three fetal non-stress tests are covered in a 280-day period or 40 weeks before a high-risk diagnosis must be on the claim.
All non-stress tests must be medically necessary.
Claim diagnoses will be reviewed for high-risk pregnancy. For billing, fetal heart monitoring is included with non-stress testing and is not separately reimbursable. Medicaid does not allow separate reimbursement for fetal monitoring performed during labor. A fetal non-stress test cannot be billed with fetal biophysical profile code 76818. Neither fetal oxytocin stress testing nor non-stress testing can be billed on the same date of service as labor room delivery RC720.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
N/A - No authorization is required
Resources
Fetal scalp blood sampling
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.