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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12465 Results

Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)

Service Code
23420 (CPT) Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Tenodesis of long tendon of biceps

Service Code
23430 (CPT) Tenodesis of long tendon of biceps
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Resection or transplantation of long tendon of biceps

Service Code
23440 (CPT) Resection or transplantation of long tendon of biceps
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, 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

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation

Service Code
23450 (CPT) Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure)

Service Code
23455 (CPT) Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Capsulorrhaphy, anterior, any type; with bone block

Service Code
23460 (CPT) Capsulorrhaphy, anterior, any type; with bone block
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Capsulorrhaphy, anterior, any type; with coracoid process transfer

Service Code
23462 (CPT) Capsulorrhaphy, anterior, any type; with coracoid process transfer
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block

Service Code
23465 (CPT) Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Capsulorrhaphy, glenohumeral joint, any type multi-directional instability

Service Code
23466 (CPT) Capsulorrhaphy, glenohumeral joint, any type multi-directional instability
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Arthroplasty, glenohumeral joint; hemiarthroplasty

Service Code
23470 (CPT) Arthroplasty, glenohumeral joint; hemiarthroplasty
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))

Service Code
23472 (CPT) Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component

Service Code
23473 (CPT) Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component

Service Code
23474 (CPT) Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Osteotomy, clavicle, with or without internal fixation;

Service Code
23480 (CPT) Osteotomy, clavicle, with or without internal fixation;
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, 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

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (includes obtaining graft and/or necessary fixation)

Service Code
23485 (CPT) Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (includes obtaining graft and/or necessary fixation)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, 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

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; clavicle

Service Code
23490 (CPT) Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; clavicle
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, 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

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; proximal humerus

Service Code
23491 (CPT) Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; proximal humerus
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, 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

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Closed treatment of clavicular fracture; without manipulation

Service Code
23500 (CPT) Closed treatment of clavicular fracture; without manipulation
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, 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

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Closed treatment of clavicular fracture; with manipulation

Service Code
23505 (CPT) Closed treatment of clavicular fracture; with manipulation
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, 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

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Open treatment of clavicular fracture, includes internal fixation, when performed

Service Code
23515 (CPT) Open treatment of clavicular fracture, includes internal fixation, when performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, 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

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.