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
Cryopreservation; embryo(s)
Service Code
89258 (CPT) Cryopreservation; embryo(s)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Cryopreservation; sperm
Service Code
89259 (CPT) Cryopreservation; sperm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sperm isolation; simple prep (eg, sperm wash and swim-up) for insemination or diagnosis with semen analysis
Service Code
89260 (CPT) Sperm isolation; simple prep (eg, sperm wash and swim-up) for insemination or diagnosis with semen analysis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sperm isolation; complex prep (eg, Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis
Service Code
89261 (CPT) Sperm isolation; complex prep (eg, Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sperm identification from testis tissue, fresh or cryopreserved
Service Code
89264 (CPT) Sperm identification from testis tissue, fresh or cryopreserved
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Insemination of oocytes
Service Code
89268 (CPT) Insemination of oocytes
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Extended culture of oocyte(s)/embryo(s), 4-7 days
Service Code
89272 (CPT) Extended culture of oocyte(s)/embryo(s), 4-7 days
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes
Service Code
89280 (CPT) Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Assisted oocyte fertilization, microtechnique; greater than 10 oocytes
Service Code
89281 (CPT) Assisted oocyte fertilization, microtechnique; greater than 10 oocytes
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos
Service Code
89290 (CPT) Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos
Service Code
89291 (CPT) Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Semen analysis; presence and/or motility of sperm including Huhner test (post coital)
Service Code
89300 (CPT) Semen analysis; presence and/or motility of sperm including Huhner test (post coital)
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
Semen analysis; motility and count (not including Huhner test)
Service Code
89310 (CPT) Semen analysis; motility and count (not including Huhner test)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Semen analysis; volume, count, motility, and differential
Service Code
89320 (CPT) Semen analysis; volume, count, motility, and differential
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Semen analysis; sperm presence and motility of sperm, if performed
Service Code
89321 (CPT) Semen analysis; sperm presence and motility of sperm, if performed
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Semen analysis; volume, count, motility, and differential using strict morphologic criteria (eg, Kruger)
Service Code
89322 (CPT) Semen analysis; volume, count, motility, and differential using strict morphologic criteria (eg, Kruger)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sperm antibodies
Service Code
89325 (CPT) Sperm antibodies
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
Sperm evaluation; hamster penetration test
Service Code
89329 (CPT) Sperm evaluation; hamster penetration test
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test
Service Code
89330 (CPT) Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated)
Service Code
89331 (CPT) Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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