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
12465 Results
Excision of malignant tumor of mandible;
Service Code
21044 (CPT) Excision of malignant tumor of mandible;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of malignant tumor of mandible; radical resection
Service Code
21045 (CPT) Excision of malignant tumor of mandible; radical resection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s])
Service Code
21046 (CPT) Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s])
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion[s])
Service Code
21047 (CPT) Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion[s])
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s])
Service Code
21048 (CPT) Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s])
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or destructive lesion[s])
Service Code
21049 (CPT) Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or destructive lesion[s])
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Condylectomy, temporomandibular joint (separate procedure)
Service Code
21050 (CPT) Condylectomy, temporomandibular joint (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Meniscectomy, partial or complete, temporomandibular joint (separate procedure)
Service Code
21060 (CPT) Meniscectomy, partial or complete, temporomandibular joint (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Coronoidectomy (separate procedure)
Service Code
21070 (CPT) Coronoidectomy (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)
Service Code
21073 (CPT) Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Impression and custom preparation; surgical obturator prosthesis
Service Code
21076 (CPT) Impression and custom preparation; surgical obturator prosthesis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Impression and custom preparation; orbital prosthesis
Service Code
21077 (CPT) Impression and custom preparation; orbital prosthesis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Impression and custom preparation; interim obturator prosthesis
Service Code
21079 (CPT) Impression and custom preparation; interim obturator prosthesis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Impression and custom preparation; definitive obturator prosthesis
Service Code
21080 (CPT) Impression and custom preparation; definitive obturator prosthesis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Impression and custom preparation; mandibular resection prosthesis
Service Code
21081 (CPT) Impression and custom preparation; mandibular resection prosthesis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Impression and custom preparation; palatal augmentation prosthesis
Service Code
21082 (CPT) Impression and custom preparation; palatal augmentation prosthesis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Impression and custom preparation; palatal lift prosthesis
Service Code
21083 (CPT) Impression and custom preparation; palatal lift prosthesis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Impression and custom preparation; speech aid prosthesis
Service Code
21084 (CPT) Impression and custom preparation; speech aid prosthesis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Impression and custom preparation; oral surgical splint
Service Code
21085 (CPT) Impression and custom preparation; oral surgical splint
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Impression and custom preparation; auricular prosthesis
Service Code
21086 (CPT) Impression and custom preparation; auricular prosthesis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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