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
Repair fistula; oronasal
Service Code
30600 (CPT) Repair fistula; oronasal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Septal or other intranasal dermatoplasty (does not include obtaining graft)
Service Code
30620 (CPT) Septal or other intranasal dermatoplasty (does not include obtaining 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 nasal septal perforations
Service Code
30630 (CPT) Repair nasal septal perforations
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial
Service Code
30801 (CPT) Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (ie, submucosal)
Service Code
30802 (CPT) Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (ie, submucosal)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method
Service Code
30901 (CPT) Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method
Service Code
30903 (CPT) Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial
Service Code
30905 (CPT) Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; subsequent
Service Code
30906 (CPT) Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; subsequent
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Ligation arteries; ethmoidal
Service Code
30915 (CPT) Ligation arteries; ethmoidal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Ligation arteries; internal maxillary artery, transantral
Service Code
30920 (CPT) Ligation arteries; internal maxillary artery, transantral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Fracture nasal inferior turbinate(s), therapeutic
Service Code
30930 (CPT) Fracture nasal inferior turbinate(s), therapeutic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted procedure, nose
Service Code
30999 (CPT) Unlisted procedure, nose
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
Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium)
Service Code
31000 (CPT) Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Lavage by cannulation; sphenoid sinus
Service Code
31002 (CPT) Lavage by cannulation; sphenoid sinus
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sinusotomy, maxillary (antrotomy); intranasal
Service Code
31020 (CPT) Sinusotomy, maxillary (antrotomy); intranasal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps
Service Code
31030 (CPT) Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with removal of antrochoanal polyps
Service Code
31032 (CPT) Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with removal of antrochoanal polyps
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Pterygomaxillary fossa surgery, any approach
Service Code
31040 (CPT) Pterygomaxillary fossa surgery, any approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sinusotomy, sphenoid, with or without biopsy;
Service Code
31050 (CPT) Sinusotomy, sphenoid, with or without biopsy;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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