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
Radiologic examination, spine; thoracic, 3 views
Service Code
72072 (CPT) Radiologic examination, spine; thoracic, 3 views
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Radiologic examination, spine; thoracic, minimum of 4 views
Service Code
72074 (CPT) Radiologic examination, spine; thoracic, minimum of 4 views
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Radiologic examination, spine; thoracolumbar junction, minimum of 2 views
Service Code
72080 (CPT) Radiologic examination, spine; thoracolumbar junction, minimum of 2 views
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view
Service Code
72081 (CPT) Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views
Service Code
72082 (CPT) Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 4 or 5 views
Service Code
72083 (CPT) Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 4 or 5 views
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); minimum of 6 views
Service Code
72084 (CPT) Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); minimum of 6 views
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Radiologic examination, spine, lumbosacral; 2 or 3 views
Service Code
72100 (CPT) Radiologic examination, spine, lumbosacral; 2 or 3 views
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Radiologic examination, spine, lumbosacral; minimum of 4 views
Service Code
72110 (CPT) Radiologic examination, spine, lumbosacral; minimum of 4 views
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views
Service Code
72114 (CPT) Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views
Service Code
72120 (CPT) Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Computed tomography, cervical spine; without contrast material
Service Code
72125 (CPT) Computed tomography, cervical spine; without contrast material
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
Computed tomography, cervical spine; with contrast material
Service Code
72126 (CPT) Computed tomography, cervical spine; with contrast material
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
Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections
Service Code
72127 (CPT) Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections
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
Computed tomography, thoracic spine; without contrast material
Service Code
72128 (CPT) Computed tomography, thoracic spine; without contrast material
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
Computed tomography, thoracic spine; with contrast material
Service Code
72129 (CPT) Computed tomography, thoracic spine; with contrast material
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
Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections
Service Code
72130 (CPT) Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections
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
Computed tomography, lumbar spine; without contrast material
Service Code
72131 (CPT) Computed tomography, lumbar spine; without contrast material
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
Computed tomography, lumbar spine; with contrast material
Service Code
72132 (CPT) Computed tomography, lumbar spine; with contrast material
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
Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections
Service Code
72133 (CPT) Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections
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
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