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12437 Results

Surface radiation therapy; orthovoltage, delivery, >150-500 kV, per fraction

Service Code
77438 (CPT) Surface radiation therapy; orthovoltage, delivery, >150-500 kV, per fraction
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

Surface radiation therapy; superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for treatment of cutaneous tumors, per course of treatment (List separately in addition to code for primary procedure)

Service Code
77439 (CPT) Surface radiation therapy; superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for treatment of cutaneous tumors, per course of treatment (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

Intraoperative radiation treatment management

Service Code
77469 (CPT) Intraoperative radiation treatment management
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation)

Service Code
77470 (CPT) Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation)
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

Proton treatment delivery; simple, without compensation

Service Code
77520 (CPT) Proton treatment delivery; simple, without compensation
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

Proton treatment delivery; simple, with compensation

Service Code
77522 (CPT) Proton treatment delivery; simple, with compensation
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

Proton treatment delivery; intermediate

Service Code
77523 (CPT) Proton treatment delivery; intermediate
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

Proton treatment delivery; complex

Service Code
77525 (CPT) Proton treatment delivery; complex
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

Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less)

Service Code
77600 (CPT) Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm)

Service Code
77605 (CPT) Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators

Service Code
77610 (CPT) Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators

Service Code
77615 (CPT) Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Hyperthermia generated by intracavitary probe(s)

Service Code
77620 (CPT) Hyperthermia generated by intracavitary probe(s)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Infusion or instillation of radioelement solution (includes 3-month follow-up care)

Service Code
77750 (CPT) Infusion or instillation of radioelement solution (includes 3-month follow-up care)
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

Intracavitary radiation source application; simple

Service Code
77761 (CPT) Intracavitary radiation source application; simple
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

Intracavitary radiation source application; intermediate

Service Code
77762 (CPT) Intracavitary radiation source application; intermediate
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

Intracavitary radiation source application; complex

Service Code
77763 (CPT) Intracavitary radiation source application; complex
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

Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel

Service Code
77767 (CPT) Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel
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

Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions

Service Code
77768 (CPT) Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions
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

Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel

Service Code
77770 (CPT) Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel
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