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
12465 Results

Excision of pilonidal cyst or sinus; complicated

Service Code
11772 (CPT) Excision of pilonidal cyst or sinus; complicated
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Injection, intralesional; up to and including 7 lesions

Service Code
11900 (CPT) Injection, intralesional; up to and including 7 lesions
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Injection, intralesional; more than 7 lesions

Service Code
11901 (CPT) Injection, intralesional; more than 7 lesions
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Breast Surgeries

Service Code
11920 (CPT) Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Breast reconstructive surgery is performed following a mastectomy to establish symmetry with the contralateral breast or following bilateral mastectomy. It includes creation of a new breast mound and nipple-areolar reconstruction. Reconstructive surgery may also include reduction mammaplasty, mastopexy, or augmentation on the contralateral breast to establish symmetry; breast implants, tissue flaps, or both may be placed where natural breast tissue has been removed.

Limits

Breast implants are not covered when used for breast enlargement for cosmetic purposes.

Removal of mammary implants or mammary implant material is not covered for cosmetic purposes.

Augmentation mammaplasty with or without prosthesis is not covered for cosmetic purposes.

Correction of inverted nipples is not covered.

Preparation of moulage for custom breast implants is not covered.

Periprosthetic capsulotomy and periprosthetic capsulectomy following augmentation are not covered.

Mastopexy is not covered except when the criteria for breast reconstructive surgery are met.

Services are also not covered when the beneficiary does not meet eligibility requirements, does not meet Section 3.0 criteria, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial.

Exclusions

Male Gynecomastia-Service is for male beneficiaries; the description specifies surgical removal of breast tissue from adult males.

Adult pathway requires persistence for more than 3 to 4 months after pathological causes are ruled out.

Adolescent pathway requires persistence for more than 6 months after pathological causes are ruled out.

For male gynecomastia specifically, coverage is not supported when the breast enlargement is due to normal transient pubertal enlargement, obesity or fatty rather than glandular tissue, drug treatments that resolve when stopped, medications, non-covered therapies, alcohol, or illicit drugs such as marijuana or anabolic steroids.

Fibrocystic disease is not a legitimate reason for prophylactic mastectomy in the absence of documented risk factors.

Place of Service

Inpatient hospital, Outpatient hospital, Office

How to Submit

N/A - No authorization is required

Resources

Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm

Service Code
11921 (CPT) Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure)

Service Code
11922 (CPT) Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (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

Subcutaneous injection of filling material (eg, collagen); 1 cc or less

Service Code
11950 (CPT) Subcutaneous injection of filling material (eg, collagen); 1 cc or less
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc

Service Code
11951 (CPT) Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc

Service Code
11952 (CPT) Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Subcutaneous injection of filling material (eg, collagen); over 10.0 cc

Service Code
11954 (CPT) Subcutaneous injection of filling material (eg, collagen); over 10.0 cc
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Insertion of tissue expander(s) for other than breast, including subsequent expansion

Service Code
11960 (CPT) Insertion of tissue expander(s) for other than breast, including subsequent expansion
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Trillium.

Replacement of tissue expander with permanent implant

Service Code
11970 (CPT) Replacement of tissue expander with permanent implant
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Removal of tissue expander without insertion of implant

Service Code
11971 (CPT) Removal of tissue expander without insertion of implant
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal, implantable contraceptive capsules

Service Code
11976 (CPT) Removal, implantable contraceptive capsules
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)

Service Code
11980 (CPT) Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Insertion, non-biodegradable drug delivery implant

Service Code
11981 (CPT) Insertion, non-biodegradable drug delivery implant
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal, non-biodegradable drug delivery implant

Service Code
11982 (CPT) Removal, non-biodegradable drug delivery implant
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal with reinsertion, non-biodegradable drug delivery implant

Service Code
11983 (CPT) Removal with reinsertion, non-biodegradable drug delivery implant
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less

Service Code
12001 (CPT) Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm

Service Code
12002 (CPT) Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required