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
12437 Results
Suture of major peripheral nerve, arm or leg, except sciatic; including transposition
Service Code
64856 (CPT) Suture of major peripheral nerve, arm or leg, except sciatic; including transposition
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of major peripheral nerve, arm or leg, except sciatic; without transposition
Service Code
64857 (CPT) Suture of major peripheral nerve, arm or leg, except sciatic; without transposition
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of sciatic nerve
Service Code
64858 (CPT) Suture of sciatic nerve
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of each additional major peripheral nerve (List separately in addition to code for primary procedure)
Service Code
64859 (CPT) Suture of each additional major peripheral nerve (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
Suture of; brachial plexus
Service Code
64861 (CPT) Suture of; brachial plexus
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of; lumbar plexus
Service Code
64862 (CPT) Suture of; lumbar plexus
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of facial nerve; extracranial
Service Code
64864 (CPT) Suture of facial nerve; extracranial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of facial nerve; infratemporal, with or without grafting
Service Code
64865 (CPT) Suture of facial nerve; infratemporal, with or without grafting
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Anastomosis; facial-spinal accessory
Service Code
64866 (CPT) Anastomosis; facial-spinal accessory
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Anastomosis; facial-hypoglossal
Service Code
64868 (CPT) Anastomosis; facial-hypoglossal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of nerve; requiring secondary or delayed suture (List separately in addition to code for primary neurorrhaphy)
Service Code
64872 (CPT) Suture of nerve; requiring secondary or delayed suture (List separately in addition to code for primary neurorrhaphy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of nerve; requiring extensive mobilization, or transposition of nerve (List separately in addition to code for nerve suture)
Service Code
64874 (CPT) Suture of nerve; requiring extensive mobilization, or transposition of nerve (List separately in addition to code for nerve suture)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Suture of nerve; requiring shortening of bone of extremity (List separately in addition to code for nerve suture)
Service Code
64876 (CPT) Suture of nerve; requiring shortening of bone of extremity (List separately in addition to code for nerve suture)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve graft (includes obtaining graft), head or neck; up to 4 cm in length
Service Code
64885 (CPT) Nerve graft (includes obtaining graft), head or neck; up to 4 cm in length
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve graft (includes obtaining graft), head or neck; more than 4 cm length
Service Code
64886 (CPT) Nerve graft (includes obtaining graft), head or neck; more than 4 cm length
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve graft (includes obtaining graft), single strand, hand or foot; up to 4 cm length
Service Code
64890 (CPT) Nerve graft (includes obtaining graft), single strand, hand or foot; up to 4 cm length
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve graft (includes obtaining graft), single strand, hand or foot; more than 4 cm length
Service Code
64891 (CPT) Nerve graft (includes obtaining graft), single strand, hand or foot; more than 4 cm length
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length
Service Code
64892 (CPT) Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve graft (includes obtaining graft), single strand, arm or leg; more than 4 cm length
Service Code
64893 (CPT) Nerve graft (includes obtaining graft), single strand, arm or leg; more than 4 cm length
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; up to 4 cm length
Service Code
64895 (CPT) Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; up to 4 cm length
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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