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

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12437 Results

Scaffold, endovascular noncoronary, resorbable drug eluting, with delivery system (implantable)

Service Code
C1743 (HCPCS) Scaffold, endovascular noncoronary, resorbable drug eluting, with delivery system (implantable)
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

Endoscope, single-use (i.e., disposable), urinary tract, imaging/illumination device (insertable)

Service Code
C1747 (HCPCS) Endoscope, single-use (i.e., disposable), urinary tract, imaging/illumination device (insertable)
Prior Authorization Required
No
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

N/A - No authorization is required

Event recorder, cardiac (implantable)

Service Code
C1764 (HCPCS) Event recorder, cardiac (implantable)
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.

Reauthorization Guidelines

See the Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

Generator, neurostimulator (implantable), nonrechargeable

Service Code
C1767 (HCPCS) Generator, neurostimulator (implantable), nonrechargeable
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.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Lead, cardioverter-defibrillator, endocardial single coil (implantable)

Service Code
C1777 (HCPCS) Lead, cardioverter-defibrillator, endocardial single coil (implantable)
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.

Reauthorization Guidelines

See the Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

Lead, neurostimulator (implantable)

Service Code
C1778 (HCPCS) Lead, neurostimulator (implantable)
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.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS

Service Code
C1779 (HCPCS) LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS
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.

Reauthorization Guidelines

See the Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

PACEMAKER, DUAL CHAMBER, RATE-RESPONSIVE (IMPLANTABLE)

Service Code
C1785 (HCPCS) PACEMAKER, DUAL CHAMBER, RATE-RESPONSIVE (IMPLANTABLE)
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.

Reauthorization Guidelines

See the Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

PACEMAKER, SINGLE CHAMBER, RATE-RESPONSIVE (IMPLANTABLE)

Service Code
C1786 (HCPCS) PACEMAKER, SINGLE CHAMBER, RATE-RESPONSIVE (IMPLANTABLE)
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.

Reauthorization Guidelines

See the Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

Patient programmer, neurostimulator

Service Code
C1787 (HCPCS) Patient programmer, neurostimulator
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.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Receiver and/or transmitter, neurostimulator (implantable)

Service Code
C1816 (HCPCS) Receiver and/or transmitter, neurostimulator (implantable)
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.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Generator, neurostimulator (implantable), with rechargeable battery and charging system

Service Code
C1820 (HCPCS) Generator, neurostimulator (implantable), with rechargeable battery and charging system
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.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system

Service Code
C1822 (HCPCS) Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system
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.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Generator, neurostimulator (implantable), nonrechargeable, with transvenous sensing and stimulation leads

Service Code
C1823 (HCPCS) Generator, neurostimulator (implantable), nonrechargeable, with transvenous sensing and stimulation leads
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.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Stent, coated/covered, with delivery system

Service Code
C1874 (HCPCS) Stent, coated/covered, with delivery system
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.

Reauthorization Guidelines

See the Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

Stent, coated/covered, without delivery system

Service Code
C1875 (HCPCS) Stent, coated/covered, without delivery system
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.

Reauthorization Guidelines

See the Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

Stent, non-coated/non-covered, with delivery system

Service Code
C1876 (HCPCS) Stent, non-coated/non-covered, with delivery system
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.

Reauthorization Guidelines

See the Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

Stent, non-coated/non-covered, without delivery system

Service Code
C1877 (HCPCS) Stent, non-coated/non-covered, without delivery system
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.

Reauthorization Guidelines

See the Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

Vena cava filter

Service Code
C1880 (HCPCS) Vena cava filter
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.

Reauthorization Guidelines

See the Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

Cardioverter-defibrillator, other than single or dual chamber (implantable)

Service Code
C1882 (HCPCS) Cardioverter-defibrillator, other than single or dual chamber (implantable)
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.

Reauthorization Guidelines

See the Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point