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
12437 Results

Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions

Service Code
74178 (CPT) Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions
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

Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s)

Service Code
74181 (CPT) Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s)
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

Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s)

Service Code
74182 (CPT) Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s)
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

Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences

Service Code
74183 (CPT) Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences
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

Magnetic resonance angiography, abdomen, with or without contrast material(s)

Service Code
74185 (CPT) Magnetic resonance angiography, abdomen, with or without contrast material(s)
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 tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material

Service Code
74261 (CPT) Computed tomographic (CT) colonography, diagnostic, including image postprocessing; 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 tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed

Service Code
74262 (CPT) Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed
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 tomographic (CT) colonography, screening, including image postprocessing

Service Code
74263 (CPT) Computed tomographic (CT) colonography, screening, including image postprocessing
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

Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation

Service Code
74712 (CPT) Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation
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.

Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure)

Service Code
74713 (CPT) Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure)
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.

Cardiac magnetic resonance imaging for morphology and function without contrast material;

Service Code
75557 (CPT) Cardiac magnetic resonance imaging for morphology and function without contrast material;
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.

Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging

Service Code
75559 (CPT) Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging
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.

Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences;

Service Code
75561 (CPT) Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences;
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.

Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging

Service Code
75563 (CPT) Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging
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.

Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure)

Service Code
75565 (CPT) Cardiac magnetic resonance imaging for velocity flow mapping (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

Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium

Service Code
75571 (CPT) Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium
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, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)

Service Code
75572 (CPT) Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)
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, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluati

Service Code
75573 (CPT) Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluati
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.

Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluatio

Service Code
75574 (CPT) Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluatio
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

Quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, derived from augmentative software analysis of the data set from a coronary computed tomographic angiography, with interpretation and report by

Service Code
75577 (CPT) Quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, derived from augmentative software analysis of the data set from a coronary computed tomographic angiography, with interpretation and report by
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required