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
Removal of vitreous, anterior approach (open sky technique or limbal incision); subtotal removal with mechanical vitrectomy
Service Code
67010 (CPT) Removal of vitreous, anterior approach (open sky technique or limbal incision); subtotal removal with mechanical vitrectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach (posterior sclerotomy)
Service Code
67015 (CPT) Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach (posterior sclerotomy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Injection of vitreous substitute, pars plana or limbal approach (fluid-gas exchange), with or without aspiration (separate procedure)
Service Code
67025 (CPT) Injection of vitreous substitute, pars plana or limbal approach (fluid-gas exchange), with or without aspiration (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of vitreous
Service Code
67027 (CPT) Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of vitreous
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Intravitreal injection of a pharmacologic agent (separate procedure)
Service Code
67028 (CPT) Intravitreal injection of a pharmacologic agent (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Discission of vitreous strands (without removal), pars plana approach
Service Code
67030 (CPT) Discission of vitreous strands (without removal), pars plana approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery (1 or more stages)
Service Code
67031 (CPT) Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery (1 or more stages)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vitrectomy, mechanical, pars plana approach;
Service Code
67036 (CPT) Vitrectomy, mechanical, pars plana approach;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation
Service Code
67039 (CPT) Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation
Service Code
67040 (CPT) Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker)
Service Code
67041 (CPT) Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil)
Service Code
67042 (CPT) Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and laser photocoagulation
Service Code
67043 (CPT) Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and laser photocoagulation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of retinal detachment, including drainage of subretinal fluid when performed; cryotherapy
Service Code
67101 (CPT) Repair of retinal detachment, including drainage of subretinal fluid when performed; cryotherapy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of retinal detachment, including drainage of subretinal fluid when performed; photocoagulation
Service Code
67105 (CPT) Repair of retinal detachment, including drainage of subretinal fluid when performed; photocoagulation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), including, when performed, implant, cryotherapy, photocoagulation, and drainage of subretinal fluid
Service Code
67107 (CPT) Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), including, when performed, implant, cryotherapy, photocoagulation, and drainage of subretinal fluid
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of retinal detachment; with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique
Service Code
67108 (CPT) Repair of retinal detachment; with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of retinal detachment; by injection of air or other gas (eg, pneumatic retinopexy)
Service Code
67110 (CPT) Repair of retinal detachment; by injection of air or other gas (eg, pneumatic retinopexy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, including, w
Service Code
67113 (CPT) Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, including, w
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Release of encircling material (posterior segment)
Service Code
67115 (CPT) Release of encircling material (posterior segment)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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