PA Lookup

Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal)

Service Code

62282 (CPT) Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal)

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

Authorization Guidelines

Pre-authorization is required for all providers unless performed on the same day as surgery. 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 is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Trillium.

Trillium iTransact Portal

Injection procedure for myelography and/or computed tomography, lumbar

Service Code

62284 (CPT) Injection procedure for myelography and/or computed tomography, lumbar

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural inj

Service Code

62287 (CPT) Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural inj

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

Trillium iTransact Portal

Injection procedure for discography, each level; lumbar

Service Code

62290 (CPT) Injection procedure for discography, each level; lumbar

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

https://www1.radmd.com/all-health-plans/trillium-health-resources

Injection procedure for discography, each level; cervical or thoracic

Service Code

62291 (CPT) Injection procedure for discography, each level; cervical or thoracic

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, 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

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar

Service Code

62292 (CPT) Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, 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

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Injection procedure, arterial, for occlusion of arteriovenous malformation, spinal

Service Code

62294 (CPT) Injection procedure, arterial, for occlusion of arteriovenous malformation, spinal

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

Authorization Guidelines

Medicaid

Diagnosis Group

Physical Health

Authorization Guidelines

See the Evolent site for specific requirements

Reauthorization Guidelines

See the Evolent site for specific requirements

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Evolent.

https://www1.radmd.com/all-health-plans/trillium-health-resources

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thora

Service Code

62321 (CPT) Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thora

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

Authorization Guidelines

See the Evolent site for specific requirements

Reauthorization Guidelines

See the Evolent site for specific requirements

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Evolent.

https://www1.radmd.com/all-health-plans/trillium-health-resources

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral

Service Code

62322 (CPT) Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

Authorization Guidelines

See the Evolent site for specific requirements

Reauthorization Guidelines

See the Evolent site for specific requirements

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Evolent.

https://www1.radmd.com/all-health-plans/trillium-health-resources

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral

Service Code

62323 (CPT) Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

Authorization Guidelines

See the Evolent site for specific requirements

Reauthorization Guidelines

See the Evolent site for specific requirements

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Evolent.

https://www1.radmd.com/all-health-plans/trillium-health-resources

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar

Service Code

62324 (CPT) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

Authorization Guidelines

Pre-authorization is required for all providers unless performed on the same day as surgery. 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 is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Trillium.

Trillium iTransact Portal

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar

Service Code

62325 (CPT) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

Authorization Guidelines

Pre-authorization is required for all providers unless performed on the same day as surgery. 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 is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Trillium.

Trillium iTransact Portal

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar

Service Code

62326 (CPT) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

Authorization Guidelines

Pre-authorization is required for all providers unless performed on the same day as surgery. 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 is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Trillium.

Trillium iTransact Portal

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar

Service Code

62327 (CPT) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

Authorization Guidelines

Pre-authorization is required for all providers unless performed on the same day as surgery. 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 is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Trillium.

Trillium iTransact Portal

Spinal puncture, lumbar, diagnostic; with fluoroscopic or CT guidance

Service Code

62328 (CPT) Spinal puncture, lumbar, diagnostic; with fluoroscopic or CT guidance

Prior Authorization Required

No

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

How to Submit

N/A - No authorization is required

If you have questions about prior authorizations, please call:

Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal)

Authorization Guidelines

Conditional Requirements

How to Submit

Injection procedure for myelography and/or computed tomography, lumbar

How to Submit

Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural inj

Authorization Guidelines

How to Submit

Injection procedure for discography, each level; lumbar

Authorization Guidelines

Reauthorization Guidelines

How to Submit

Injection procedure for discography, each level; cervical or thoracic

Authorization Guidelines

Conditional Requirements

How to Submit

Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar

Authorization Guidelines

Conditional Requirements

How to Submit

Injection procedure, arterial, for occlusion of arteriovenous malformation, spinal

Authorization Guidelines

Conditional Requirements

How to Submit

Myelography via lumbar injection, including radiological supervision and interpretation; cervical

How to Submit

Myelography via lumbar injection, including radiological supervision and interpretation; thoracic

How to Submit

Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral

How to Submit

Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical)

How to Submit

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thora

Authorization Guidelines

Reauthorization Guidelines

Conditional Requirements

How to Submit

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thora

Authorization Guidelines

Reauthorization Guidelines

Conditional Requirements

How to Submit

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral

Authorization Guidelines

Reauthorization Guidelines

Conditional Requirements

How to Submit

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral

Authorization Guidelines

Reauthorization Guidelines

Conditional Requirements

How to Submit

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar

Authorization Guidelines

Conditional Requirements

How to Submit

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar

Authorization Guidelines

Conditional Requirements

How to Submit

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar

Authorization Guidelines

Conditional Requirements

How to Submit

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar

Authorization Guidelines

Conditional Requirements

How to Submit

Spinal puncture, lumbar, diagnostic; with fluoroscopic or CT guidance

How to Submit