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
Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous
Service Code
61630 (CPT) Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed
Service Code
61635 (CPT) Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel
Service Code
61640 (CPT) Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in same vascular territory (List separately in addition to code for primary procedure)
Service Code
61641 (CPT) Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in same vascular territory (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different vascular territory (List separately in addition to code for primary procedure)
Service Code
61642 (CPT) Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different vascular territory (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(
Service Code
61645 (CPT) Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; initial vascular territory
Service Code
61650 (CPT) Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; initial vascular territory
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; each additional vascular territory (List separately in addition
Service Code
61651 (CPT) Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; each additional vascular territory (List separately in addition
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Surgery of intracranial arteriovenous malformation; supratentorial, simple
Service Code
61680 (CPT) Surgery of intracranial arteriovenous malformation; supratentorial, simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Surgery of intracranial arteriovenous malformation; supratentorial, complex
Service Code
61682 (CPT) Surgery of intracranial arteriovenous malformation; supratentorial, complex
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Surgery of intracranial arteriovenous malformation; infratentorial, simple
Service Code
61684 (CPT) Surgery of intracranial arteriovenous malformation; infratentorial, simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Surgery of intracranial arteriovenous malformation; infratentorial, complex
Service Code
61686 (CPT) Surgery of intracranial arteriovenous malformation; infratentorial, complex
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Surgery of intracranial arteriovenous malformation; dural, simple
Service Code
61690 (CPT) Surgery of intracranial arteriovenous malformation; dural, simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Surgery of intracranial arteriovenous malformation; dural, complex
Service Code
61692 (CPT) Surgery of intracranial arteriovenous malformation; dural, complex
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation
Service Code
61697 (CPT) Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Surgery of complex intracranial aneurysm, intracranial approach; vertebrobasilar circulation
Service Code
61698 (CPT) Surgery of complex intracranial aneurysm, intracranial approach; vertebrobasilar circulation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation
Service Code
61700 (CPT) Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation
Service Code
61702 (CPT) Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid artery (Selverstone-Crutchfield type)
Service Code
61703 (CPT) Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid artery (Selverstone-Crutchfield type)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial and cervical occlusion of carotid artery
Service Code
61705 (CPT) Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial and cervical occlusion of carotid artery
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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