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Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12465 Results

Insertion, nasal septal prosthesis (button)

Service Code
30220 (CPT) Insertion, nasal septal prosthesis (button)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal foreign body, intranasal; office type procedure

Service Code
30300 (CPT) Removal foreign body, intranasal; office type procedure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal foreign body, intranasal; requiring general anesthesia

Service Code
30310 (CPT) Removal foreign body, intranasal; requiring general anesthesia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal foreign body, intranasal; by lateral rhinotomy

Service Code
30320 (CPT) Removal foreign body, intranasal; by lateral rhinotomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip

Service Code
30400 (CPT) Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

The provider shall submit the following:

  • a. the prior approval request; and
  • b. all health care records and any other records that support the beneficiary has

met the specific criteria in Subsection 3.2.1 of this policy including:

  • 1. Location and cause of the defect or deformity;
  • 2. Pre-operative medical photographs of the defect consisting of frontal,

lateral, and columellar reviews. Medical photographs should be clearly marked with:

  • A. the beneficiary’s first and last name;
  • B. the beneficiary’s identification number;
  • C. the provider’s name and NPI;
  • D. and the date the photographs were taken;
  • 3. A list of the CPT codes describing the procedure to be performed;
  • 4. Documentation of frequency, severity, and description of symptoms;
  • 5. Documentation of the number of sinus infections that have occurred in

the last 365 days when applicable;

  • 6. Documentation of the number of episodes of epistaxis that have occurred

when applicable;

  • 7. Bodily function that will be improved or restored;
  • 8. Medical records documenting the history of the trauma or injury (if

applicable), with the date of injury and any other related surgeries;

  • 9. Documentation of sleep apnea and symptoms of breathing obstruction, if

applicable, including consecutive treatment rendered; and

  • 10. Postoperative plan of care.

Note: If the Medicaid beneficiary is under 21 years of age, information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

How to Submit

Please submit your request to Trillium Health Resources

Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip

Service Code
30410 (CPT) Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

The provider shall submit the following:

  • a. the prior approval request; and
  • b. all health care records and any other records that support the beneficiary has

met the specific criteria in Subsection 3.2.1 of this policy including:

  • 1. Location and cause of the defect or deformity;
  • 2. Pre-operative medical photographs of the defect consisting of frontal,

lateral, and columellar reviews. Medical photographs should be clearly marked with:

  • A. the beneficiary’s first and last name;
  • B. the beneficiary’s identification number;
  • C. the provider’s name and NPI;
  • D. and the date the photographs were taken;
  • 3. A list of the CPT codes describing the procedure to be performed;
  • 4. Documentation of frequency, severity, and description of symptoms;
  • 5. Documentation of the number of sinus infections that have occurred in

the last 365 days when applicable;

  • 6. Documentation of the number of episodes of epistaxis that have occurred

when applicable;

  • 7. Bodily function that will be improved or restored;
  • 8. Medical records documenting the history of the trauma or injury (if

applicable), with the date of injury and any other related surgeries;

  • 9. Documentation of sleep apnea and symptoms of breathing obstruction, if

applicable, including consecutive treatment rendered; and

  • 10. Postoperative plan of care.

Note: If the Medicaid beneficiary is under 21 years of age, information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

How to Submit

Please submit your request to Trillium Health Resources

Rhinoplasty, primary; including major septal repair

Service Code
30420 (CPT) Rhinoplasty, primary; including major septal repair
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

The provider shall submit the following:

  • a. the prior approval request; and
  • b. all health care records and any other records that support the beneficiary has

met the specific criteria in Subsection 3.2.1 of this policy including:

  • 1. Location and cause of the defect or deformity;
  • 2. Pre-operative medical photographs of the defect consisting of frontal,

lateral, and columellar reviews. Medical photographs should be clearly marked with:

  • A. the beneficiary’s first and last name;
  • B. the beneficiary’s identification number;
  • C. the provider’s name and NPI;
  • D. and the date the photographs were taken;
  • 3. A list of the CPT codes describing the procedure to be performed;
  • 4. Documentation of frequency, severity, and description of symptoms;
  • 5. Documentation of the number of sinus infections that have occurred in

the last 365 days when applicable;

  • 6. Documentation of the number of episodes of epistaxis that have occurred

when applicable;

  • 7. Bodily function that will be improved or restored;
  • 8. Medical records documenting the history of the trauma or injury (if

applicable), with the date of injury and any other related surgeries;

  • 9. Documentation of sleep apnea and symptoms of breathing obstruction, if

applicable, including consecutive treatment rendered; and

  • 10. Postoperative plan of care.

Note: If the Medicaid beneficiary is under 21 years of age, information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

How to Submit

Please submit your request to Trillium Health Resources

Rhinoplasty, secondary; minor revision (small amount of nasal tip work)

Service Code
30430 (CPT) Rhinoplasty, secondary; minor revision (small amount of nasal tip work)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

The provider shall submit the following:

  • a. the prior approval request; and
  • b. all health care records and any other records that support the beneficiary has

met the specific criteria in Subsection 3.2.1 of this policy including:

  • 1. Location and cause of the defect or deformity;
  • 2. Pre-operative medical photographs of the defect consisting of frontal,

lateral, and columellar reviews. Medical photographs should be clearly marked with:

  • A. the beneficiary’s first and last name;
  • B. the beneficiary’s identification number;
  • C. the provider’s name and NPI;
  • D. and the date the photographs were taken;
  • 3. A list of the CPT codes describing the procedure to be performed;
  • 4. Documentation of frequency, severity, and description of symptoms;
  • 5. Documentation of the number of sinus infections that have occurred in

the last 365 days when applicable;

  • 6. Documentation of the number of episodes of epistaxis that have occurred

when applicable;

  • 7. Bodily function that will be improved or restored;
  • 8. Medical records documenting the history of the trauma or injury (if

applicable), with the date of injury and any other related surgeries;

  • 9. Documentation of sleep apnea and symptoms of breathing obstruction, if

applicable, including consecutive treatment rendered; and

  • 10. Postoperative plan of care.

Note: If the Medicaid beneficiary is under 21 years of age, information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

How to Submit

Please submit your request to Trillium Health Resources

Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)

Service Code
30435 (CPT) Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

The provider shall submit the following:

  • a. the prior approval request; and
  • b. all health care records and any other records that support the beneficiary has

met the specific criteria in Subsection 3.2.1 of this policy including:

  • 1. Location and cause of the defect or deformity;
  • 2. Pre-operative medical photographs of the defect consisting of frontal,

lateral, and columellar reviews. Medical photographs should be clearly marked with:

  • A. the beneficiary’s first and last name;
  • B. the beneficiary’s identification number;
  • C. the provider’s name and NPI;
  • D. and the date the photographs were taken;
  • 3. A list of the CPT codes describing the procedure to be performed;
  • 4. Documentation of frequency, severity, and description of symptoms;
  • 5. Documentation of the number of sinus infections that have occurred in

the last 365 days when applicable;

  • 6. Documentation of the number of episodes of epistaxis that have occurred

when applicable;

  • 7. Bodily function that will be improved or restored;
  • 8. Medical records documenting the history of the trauma or injury (if

applicable), with the date of injury and any other related surgeries;

  • 9. Documentation of sleep apnea and symptoms of breathing obstruction, if

applicable, including consecutive treatment rendered; and

  • 10. Postoperative plan of care.

Note: If the Medicaid beneficiary is under 21 years of age, information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

How to Submit

Please submit your request to Trillium Health Resources

Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)

Service Code
30450 (CPT) Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

The provider shall submit the following:

  • a. the prior approval request; and
  • b. all health care records and any other records that support the beneficiary has

met the specific criteria in Subsection 3.2.1 of this policy including:

  • 1. Location and cause of the defect or deformity;
  • 2. Pre-operative medical photographs of the defect consisting of frontal,

lateral, and columellar reviews. Medical photographs should be clearly marked with:

  • A. the beneficiary’s first and last name;
  • B. the beneficiary’s identification number;
  • C. the provider’s name and NPI;
  • D. and the date the photographs were taken;
  • 3. A list of the CPT codes describing the procedure to be performed;
  • 4. Documentation of frequency, severity, and description of symptoms;
  • 5. Documentation of the number of sinus infections that have occurred in

the last 365 days when applicable;

  • 6. Documentation of the number of episodes of epistaxis that have occurred

when applicable;

  • 7. Bodily function that will be improved or restored;
  • 8. Medical records documenting the history of the trauma or injury (if

applicable), with the date of injury and any other related surgeries;

  • 9. Documentation of sleep apnea and symptoms of breathing obstruction, if

applicable, including consecutive treatment rendered; and

  • 10. Postoperative plan of care.

Note: If the Medicaid beneficiary is under 21 years of age, information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

How to Submit

Please submit your request to Trillium Health Resources

Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only

Service Code
30460 (CPT) Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only
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

Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies

Service Code
30462 (CPT) Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies
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

Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction)

Service Code
30465 (CPT) Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction)
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

Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s)

Service Code
30468 (CPT) Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s)
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

Repair of nasal valve collapse with low energy, temperature-controlled (ie, radiofrequency) subcutaneous/submucosal remodeling

Service Code
30469 (CPT) Repair of nasal valve collapse with low energy, temperature-controlled (ie, radiofrequency) subcutaneous/submucosal remodeling
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

Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft

Service Code
30520 (CPT) Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft
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

Repair choanal atresia; intranasal

Service Code
30540 (CPT) Repair choanal atresia; intranasal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair choanal atresia; transpalatine

Service Code
30545 (CPT) Repair choanal atresia; transpalatine
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Lysis intranasal synechia

Service Code
30560 (CPT) Lysis intranasal synechia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair fistula; oromaxillary (combine with 31030 if antrotomy is included)

Service Code
30580 (CPT) Repair fistula; oromaxillary (combine with 31030 if antrotomy is included)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required