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

Filter By:
Clear Filters
12465 Results

Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; percutaneous, not requiring laminectomy

Service Code
63741 (CPT) Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; percutaneous, not requiring laminectomy
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.

Replacement, irrigation or revision of lumbosubarachnoid shunt

Service Code
63744 (CPT) Replacement, irrigation or revision of lumbosubarachnoid shunt
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.

Removal of entire lumbosubarachnoid shunt system without replacement

Service Code
63746 (CPT) Removal of entire lumbosubarachnoid shunt system without replacement
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(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular)

Service Code
64400 (CPT) Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular)
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.

Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve

Service Code
64405 (CPT) Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve
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.

Injection(s), anesthetic agent(s) and/or steroid; vagus nerve

Service Code
64408 (CPT) Injection(s), anesthetic agent(s) and/or steroid; vagus nerve
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.

Injection(s), anesthetic agent(s) and/or steroid; brachial plexus

Service Code
64415 (CPT) Injection(s), anesthetic agent(s) and/or steroid; brachial plexus
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.

Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, continuous infusion by catheter (including catheter placement)

Service Code
64416 (CPT) Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, continuous infusion by catheter (including catheter placement)
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.

Injection(s), anesthetic agent(s) and/or steroid; axillary nerve

Service Code
64417 (CPT) Injection(s), anesthetic agent(s) and/or steroid; axillary nerve
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.

Injection(s), anesthetic agent(s) and/or steroid; suprascapular nerve

Service Code
64418 (CPT) Injection(s), anesthetic agent(s) and/or steroid; suprascapular nerve
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.

Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level

Service Code
64420 (CPT) Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level
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.

Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, each additional level (List separately in addition to code for primary procedure)

Service Code
64421 (CPT) Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, each additional level (List separately in addition to code for primary procedure)
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.

Injection(s), anesthetic agent(s) and/or steroid; ilioinguinal, iliohypogastric nerves

Service Code
64425 (CPT) Injection(s), anesthetic agent(s) and/or steroid; ilioinguinal, iliohypogastric nerves
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Injection(s), anesthetic agent(s) and/or steroid; pudendal nerve

Service Code
64430 (CPT) Injection(s), anesthetic agent(s) and/or steroid; pudendal nerve
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.

Injection(s), anesthetic agent(s) and/or steroid; paracervical (uterine) nerve

Service Code
64435 (CPT) Injection(s), anesthetic agent(s) and/or steroid; paracervical (uterine) nerve
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve

Service Code
64445 (CPT) Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve
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.

Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, continuous infusion by catheter (including catheter placement)

Service Code
64446 (CPT) Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, continuous infusion by catheter (including catheter placement)
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.

Injection(s), anesthetic agent(s) and/or steroid; femoral nerve

Service Code
64447 (CPT) Injection(s), anesthetic agent(s) and/or steroid; femoral nerve
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.

Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, continuous infusion by catheter (including catheter placement)

Service Code
64448 (CPT) Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, continuous infusion by catheter (including catheter placement)
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.

Injection(s), anesthetic agent(s) and/or steroid; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement)

Service Code
64449 (CPT) Injection(s), anesthetic agent(s) and/or steroid; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement)
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.