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

Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based

Service Code
77371 (CPT) Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based

Service Code
77372 (CPT) Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions

Service Code
77373 (CPT) Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple

Service Code
77385 (CPT) Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex

Service Code
77386 (CPT) Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed

Service Code
77387 (CPT) Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Radiation treatment delivery, superficial and/or ortho voltage, per day

Service Code
77401 (CPT) Radiation treatment delivery, superficial and/or ortho voltage, per day
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Radiation treatment delivery; Level 1 (eg, single-electron field, multiple-electron fields, or 2D photons), including imaging guidance, when performed

Service Code
77402 (CPT) Radiation treatment delivery; Level 1 (eg, single-electron field, multiple-electron fields, or 2D photons), including imaging guidance, when performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Radiation treatment delivery; Level 2, single-isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed

Service Code
77407 (CPT) Radiation treatment delivery; Level 2, single-isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (eg, 2D, 3D, or IMRT) or a single-isocenter photon therapy (eg, 3D or IMRT) with active motion management, or total skin electrons, or mixed-electron/photon field(s), including imaging guidance, when performed

Service Code
77412 (CPT) Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (eg, 2D, 3D, or IMRT) or a single-isocenter photon therapy (eg, 3D or IMRT) with active motion management, or total skin electrons, or mixed-electron/photon field(s), including imaging guidance, when performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Therapeutic radiology port image(s)

Service Code
77417 (CPT) Therapeutic radiology port image(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

High energy neutron radiation treatment delivery, 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s)

Service Code
77423 (CPT) High energy neutron radiation treatment delivery, 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Intraoperative radiation treatment delivery, x-ray, single treatment session

Service Code
77424 (CPT) Intraoperative radiation treatment delivery, x-ray, single treatment session
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Intraoperative radiation treatment delivery, electrons, single treatment session

Service Code
77425 (CPT) Intraoperative radiation treatment delivery, electrons, single treatment session
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Radiation treatment management, 5 treatments

Service Code
77427 (CPT) Radiation treatment management, 5 treatments
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only

Service Code
77431 (CPT) Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)

Service Code
77432 (CPT) Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions

Service Code
77435 (CPT) Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting

Service Code
77436 (CPT) Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Surface radiation therapy; superficial, delivery,</=150 kV, per fraction (eg, electronic brachytherapy)

Service Code
77437 (CPT) Surface radiation therapy; superficial, delivery,</=150 kV, per fraction (eg, electronic brachytherapy)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology