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

Adaptor/extension, pacing lead or neurostimulator lead (implantable)

Service Code
C1883 (HCPCS) Adaptor/extension, pacing lead or neurostimulator lead (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, cardioverter-defibrillator, endocardial dual coil (implantable)

Service Code
C1895 (HCPCS) Lead, cardioverter-defibrillator, endocardial dual 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, cardioverter-defibrillator, other than endocardial single or dual coil (implantable)

Service Code
C1896 (HCPCS) Lead, cardioverter-defibrillator, other than endocardial single or dual 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 test kit (implantable)

Service Code
C1897 (HCPCS) Lead, neurostimulator test kit (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, OTHER THAN TRANSVENOUS VDD SINGLE PASS

Service Code
C1898 (HCPCS) LEAD, PACEMAKER, OTHER THAN 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

Lead, pacemaker/cardioverter-defibrillator combination (implantable

Service Code
C1899 (HCPCS) Lead, pacemaker/cardioverter-defibrillator combination (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 LEFT VENTRICULAR CORONARY VENOUS SYSTEM

Service Code
C1900 (HCPCS) LEAD LEFT VENTRICULAR CORONARY VENOUS 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-coronary, temporary, without delivery system

Service Code
C2617 (HCPCS) Stent, non-coronary, temporary, 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

PACEMAKER, DUAL CHAMBER, NON RATE-RESPONSIVE (IMPLANTABLE)

Service Code
C2619 (HCPCS) PACEMAKER, DUAL CHAMBER, NON 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, NON RATE-RESPONSIVE (IMPLANTABLE)

Service Code
C2620 (HCPCS) PACEMAKER, SINGLE CHAMBER, NON 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, OTHER THAN SINGLE OR DUAL CHAMBER (IMPLANTABLE)

Service Code
C2621 (HCPCS) PACEMAKER, 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

CATHETER TRNSLUM ANGPLASTY DRUG-COATED NON-LASER

Service Code
C2623 (HCPCS) CATHETER TRNSLUM ANGPLASTY DRUG-COATED NON-LASER
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-coronary, temporary, with delivery system

Service Code
C2625 (HCPCS) Stent, non-coronary, temporary, 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

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s)

Service Code
C7562 (HCPCS) Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s)
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

Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to p

Service Code
C7563 (HCPCS) Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to p
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

Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance with intravascular ultrasound (noncoronary vessel(s)) during diagnostic evaluation and/or therapeutic i

Service Code
C7564 (HCPCS) Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance with intravascular ultrasound (noncoronary vessel(s)) during diagnostic evaluation and/or therapeutic i
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

Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s)

Service Code
C7565 (HCPCS) Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s)
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

Arthrodesis, interphalangeal joints, with or without internal fixation, with autografts (includes obtaining grafts)

Service Code
C7566 (HCPCS) Arthrodesis, interphalangeal joints, with or without internal fixation, with autografts (includes obtaining grafts)
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

Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed, with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i), with computer-assisted image-guided navigation

Service Code
C7567 (HCPCS) Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed, with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i), with computer-assisted image-guided navigation
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

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with intravascular doppler velocity and/or pressure derived coronary flow reserve

Service Code
C7568 (HCPCS) Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with intravascular doppler velocity and/or pressure derived coronary flow reserve
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