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

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12465 Results

Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch

Service Code
64450 (CPT) Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch
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; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)

Service Code
64451 (CPT) Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)
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; genicular nerve branches, including imaging guidance, when performed

Service Code
64454 (CPT) Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed
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; plantar common digital nerve(s) (eg, Morton's neuroma)

Service Code
64455 (CPT) Injection(s), anesthetic agent(s) and/or steroid; plantar common digital nerve(s) (eg, Morton's neuroma)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed)

Service Code
64461 (CPT) Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed)
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.

Paravertebral block (PVB) (paraspinous block), thoracic; second and any additional injection site(s) (includes imaging guidance, when performed) (List separately in addition to code for primary procedure)

Service Code
64462 (CPT) Paravertebral block (PVB) (paraspinous block), thoracic; second and any additional injection site(s) (includes imaging guidance, when performed) (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.

Paravertebral block (PVB) (paraspinous block), thoracic; continuous infusion by catheter (includes imaging guidance, when performed)

Service Code
64463 (CPT) Paravertebral block (PVB) (paraspinous block), thoracic; continuous infusion by catheter (includes imaging guidance, when performed)
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; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level

Service Code
64479 (CPT) Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level
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.

Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

Service Code
64480 (CPT) Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, 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

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.

Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level

Service Code
64483 (CPT) Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level
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.

Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Service Code
64484 (CPT) Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, 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

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.

Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed)

Service Code
64486 (CPT) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed)
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.

Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by continuous infusion(s) (includes imaging guidance, when performed)

Service Code
64487 (CPT) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by continuous infusion(s) (includes imaging guidance, when performed)
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.

Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed)

Service Code
64488 (CPT) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed)
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.

Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by continuous infusions (includes imaging guidance, when performed)

Service Code
64489 (CPT) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by continuous infusions (includes imaging guidance, when performed)
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), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

Service Code
64490 (CPT) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level
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.

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary proced

Service Code
64491 (CPT) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary proced
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.

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to co

Service Code
64492 (CPT) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to co
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.

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

Service Code
64493 (CPT) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
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.

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)

Service Code
64494 (CPT) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)
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.