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
Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment
How to Submit
N/A - No authorization is required
Repair lung hernia through chest wall
How to Submit
N/A - No authorization is required
Closure of chest wall following open flap drainage for empyema (Clagett type procedure)
How to Submit
N/A - No authorization is required
Open closure of major bronchial fistula
How to Submit
N/A - No authorization is required
Major reconstruction, chest wall (posttraumatic)
How to Submit
N/A - No authorization is required
Donor pneumonectomy(s) (including cold preservation), from cadaver donor
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
Lung transplant, single; without cardiopulmonary bypass
Single lung transplantation begins with a thoracotomy, which is a surgical procedure where an incision is made to open the chest cavity. After removal of the native lung, the major vessels are anastomosed (connected) to the donor lung and then to the bronchi. The bronchi are the larger air passages of the lungs.
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
Exclusions
Lung or lobar lung transplantation is also not covered when any listed contraindication is present, including active drug or alcohol use or tobacco use within the last six months; obesity more than 20-30% over ideal body weight at transplant; contraindication to immunosuppressive drugs; multiple uncorrectable congenital abnormalities significantly affecting quality and duration of life; non-curable chronic extrapulmonary infection including chronic active hepatitis B or C; colonization with highly resistant or virulent bacteria, fungi, or mycobacteria as a relative contraindication in comprehensive evaluation; current potentially life-threatening malignancy; bone marrow failure; severe congenital immunodeficiency; significant or advanced other disease such as hepatic dysfunction, renal dysfunction, or coronary artery disease not amenable to intervention or bypass with significant left ventricular impairment; other systemic disease impairing function or expected duration of life; severe cerebral dysfunction affecting quality of life or ability to comply; behavioral or psychiatric disorder likely to compromise adherence; advanced physiologic age; emotional problems or recent substance use including smoking; history of non-compliance with medical management; or absence of a consistent or reliable social support system. Medicaid reimburses only actual donor transplant-related medical expenses and does not reimburse for unsuccessful donor searches. For living organ donations, reimbursement is only for the approved donor.
Diagnosis Requirements
Specific covered indications require irreversible, progressively disabling, end-stage pulmonary disease in carefully selected beneficiaries, including debilitating lung disease meeting New York Heart Association Class III functional status after maximal rehabilitation and one of the following conditions: idiopathic or interstitial pulmonary fibrosis with significant impairment of forced vital capacity such as less than 65% predicted; cystic fibrosis requiring both lungs with severe impairment of forced vital capacity such as less than 40% predicted, forced expiratory volume in one second such as less than 30% predicted, and room air partial pressure of oxygen such as less than 60 mmHg; primary pulmonary hypertension; emphysema with post-bronchodilator FEV1 less than 25% predicted; bilateral bronchiectasis; alpha-1 antitrypsin deficiency; bronchopulmonary dysplasia; sarcoidosis; scleroderma; lymphangiomyomatosis; eosinophilic granuloma; bronchiolitis obliterans; recurrent pulmonary embolism; pulmonary hypertension due to cardiac disease; Eisenmenger's syndrome; or chronic obstructive pulmonary disease. Additional clinical requirements are that the beneficiary and caregiver are willing and capable of complying with the post-transplant treatment plan and that the beneficiary has adequate cardiac status. If the beneficiary is HIV-positive or has AIDS, the case must be evaluated individually and requires CD4 count greater than 200 cells/mm-3 for more than 6 months, undetectable HIV-1 RNA, stable antiretroviral therapy for more than 3 months, no other AIDS complications such as opportunistic infection or neoplasm, and meeting all other transplant criteria.
Place of Service
Acute inpatient hospital
How to Submit
Please submit your request to Carolina Complete Health
Resources
Lung transplant, single; with cardiopulmonary bypass
Single lung transplantation begins with a thoracotomy, which is a surgical procedure where an incision is made to open the chest cavity. After removal of the native lung, the major vessels are anastomosed (connected) to the donor lung and then to the bronchi. The bronchi are the larger air passages of the lungs.
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
Exclusions
Lung or lobar lung transplantation is also not covered when any listed contraindication is present, including active drug or alcohol use or tobacco use within the last six months; obesity more than 20-30% over ideal body weight at transplant; contraindication to immunosuppressive drugs; multiple uncorrectable congenital abnormalities significantly affecting quality and duration of life; non-curable chronic extrapulmonary infection including chronic active hepatitis B or C; colonization with highly resistant or virulent bacteria, fungi, or mycobacteria as a relative contraindication in comprehensive evaluation; current potentially life-threatening malignancy; bone marrow failure; severe congenital immunodeficiency; significant or advanced other disease such as hepatic dysfunction, renal dysfunction, or coronary artery disease not amenable to intervention or bypass with significant left ventricular impairment; other systemic disease impairing function or expected duration of life; severe cerebral dysfunction affecting quality of life or ability to comply; behavioral or psychiatric disorder likely to compromise adherence; advanced physiologic age; emotional problems or recent substance use including smoking; history of non-compliance with medical management; or absence of a consistent or reliable social support system. Medicaid reimburses only actual donor transplant-related medical expenses and does not reimburse for unsuccessful donor searches. For living organ donations, reimbursement is only for the approved donor.
Diagnosis Requirements
Specific covered indications require irreversible, progressively disabling, end-stage pulmonary disease in carefully selected beneficiaries, including debilitating lung disease meeting New York Heart Association Class III functional status after maximal rehabilitation and one of the following conditions: idiopathic or interstitial pulmonary fibrosis with significant impairment of forced vital capacity such as less than 65% predicted; cystic fibrosis requiring both lungs with severe impairment of forced vital capacity such as less than 40% predicted, forced expiratory volume in one second such as less than 30% predicted, and room air partial pressure of oxygen such as less than 60 mmHg; primary pulmonary hypertension; emphysema with post-bronchodilator FEV1 less than 25% predicted; bilateral bronchiectasis; alpha-1 antitrypsin deficiency; bronchopulmonary dysplasia; sarcoidosis; scleroderma; lymphangiomyomatosis; eosinophilic granuloma; bronchiolitis obliterans; recurrent pulmonary embolism; pulmonary hypertension due to cardiac disease; Eisenmenger's syndrome; or chronic obstructive pulmonary disease. Additional clinical requirements are that the beneficiary and caregiver are willing and capable of complying with the post-transplant treatment plan and that the beneficiary has adequate cardiac status. If the beneficiary is HIV-positive or has AIDS, the case must be evaluated individually and requires CD4 count greater than 200 cells/mm-3 for more than 6 months, undetectable HIV-1 RNA, stable antiretroviral therapy for more than 3 months, no other AIDS complications such as opportunistic infection or neoplasm, and meeting all other transplant criteria.
Place of Service
Acute inpatient hospital
How to Submit
Please submit your request to Carolina Complete Health
Resources
Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass
Single lung transplantation begins with a thoracotomy, which is a surgical procedure where an incision is made to open the chest cavity. After removal of the native lung, the major vessels are anastomosed (connected) to the donor lung and then to the bronchi. The bronchi are the larger air passages of the lungs.
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
Exclusions
Lung or lobar lung transplantation is also not covered when any listed contraindication is present, including active drug or alcohol use or tobacco use within the last six months; obesity more than 20-30% over ideal body weight at transplant; contraindication to immunosuppressive drugs; multiple uncorrectable congenital abnormalities significantly affecting quality and duration of life; non-curable chronic extrapulmonary infection including chronic active hepatitis B or C; colonization with highly resistant or virulent bacteria, fungi, or mycobacteria as a relative contraindication in comprehensive evaluation; current potentially life-threatening malignancy; bone marrow failure; severe congenital immunodeficiency; significant or advanced other disease such as hepatic dysfunction, renal dysfunction, or coronary artery disease not amenable to intervention or bypass with significant left ventricular impairment; other systemic disease impairing function or expected duration of life; severe cerebral dysfunction affecting quality of life or ability to comply; behavioral or psychiatric disorder likely to compromise adherence; advanced physiologic age; emotional problems or recent substance use including smoking; history of non-compliance with medical management; or absence of a consistent or reliable social support system. Medicaid reimburses only actual donor transplant-related medical expenses and does not reimburse for unsuccessful donor searches. For living organ donations, reimbursement is only for the approved donor.
Diagnosis Requirements
Specific covered indications require irreversible, progressively disabling, end-stage pulmonary disease in carefully selected beneficiaries, including debilitating lung disease meeting New York Heart Association Class III functional status after maximal rehabilitation and one of the following conditions: idiopathic or interstitial pulmonary fibrosis with significant impairment of forced vital capacity such as less than 65% predicted; cystic fibrosis requiring both lungs with severe impairment of forced vital capacity such as less than 40% predicted, forced expiratory volume in one second such as less than 30% predicted, and room air partial pressure of oxygen such as less than 60 mmHg; primary pulmonary hypertension; emphysema with post-bronchodilator FEV1 less than 25% predicted; bilateral bronchiectasis; alpha-1 antitrypsin deficiency; bronchopulmonary dysplasia; sarcoidosis; scleroderma; lymphangiomyomatosis; eosinophilic granuloma; bronchiolitis obliterans; recurrent pulmonary embolism; pulmonary hypertension due to cardiac disease; Eisenmenger's syndrome; or chronic obstructive pulmonary disease. Additional clinical requirements are that the beneficiary and caregiver are willing and capable of complying with the post-transplant treatment plan and that the beneficiary has adequate cardiac status. If the beneficiary is HIV-positive or has AIDS, the case must be evaluated individually and requires CD4 count greater than 200 cells/mm-3 for more than 6 months, undetectable HIV-1 RNA, stable antiretroviral therapy for more than 3 months, no other AIDS complications such as opportunistic infection or neoplasm, and meeting all other transplant criteria.
Place of Service
Acute inpatient hospital
How to Submit
Please submit your request to Carolina Complete Health
Resources
Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass
Single lung transplantation begins with a thoracotomy, which is a surgical procedure where an incision is made to open the chest cavity. After removal of the native lung, the major vessels are anastomosed (connected) to the donor lung and then to the bronchi. The bronchi are the larger air passages of the lungs.
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
Exclusions
Lung or lobar lung transplantation is also not covered when any listed contraindication is present, including active drug or alcohol use or tobacco use within the last six months; obesity more than 20-30% over ideal body weight at transplant; contraindication to immunosuppressive drugs; multiple uncorrectable congenital abnormalities significantly affecting quality and duration of life; non-curable chronic extrapulmonary infection including chronic active hepatitis B or C; colonization with highly resistant or virulent bacteria, fungi, or mycobacteria as a relative contraindication in comprehensive evaluation; current potentially life-threatening malignancy; bone marrow failure; severe congenital immunodeficiency; significant or advanced other disease such as hepatic dysfunction, renal dysfunction, or coronary artery disease not amenable to intervention or bypass with significant left ventricular impairment; other systemic disease impairing function or expected duration of life; severe cerebral dysfunction affecting quality of life or ability to comply; behavioral or psychiatric disorder likely to compromise adherence; advanced physiologic age; emotional problems or recent substance use including smoking; history of non-compliance with medical management; or absence of a consistent or reliable social support system. Medicaid reimburses only actual donor transplant-related medical expenses and does not reimburse for unsuccessful donor searches. For living organ donations, reimbursement is only for the approved donor.
Diagnosis Requirements
Specific covered indications require irreversible, progressively disabling, end-stage pulmonary disease in carefully selected beneficiaries, including debilitating lung disease meeting New York Heart Association Class III functional status after maximal rehabilitation and one of the following conditions: idiopathic or interstitial pulmonary fibrosis with significant impairment of forced vital capacity such as less than 65% predicted; cystic fibrosis requiring both lungs with severe impairment of forced vital capacity such as less than 40% predicted, forced expiratory volume in one second such as less than 30% predicted, and room air partial pressure of oxygen such as less than 60 mmHg; primary pulmonary hypertension; emphysema with post-bronchodilator FEV1 less than 25% predicted; bilateral bronchiectasis; alpha-1 antitrypsin deficiency; bronchopulmonary dysplasia; sarcoidosis; scleroderma; lymphangiomyomatosis; eosinophilic granuloma; bronchiolitis obliterans; recurrent pulmonary embolism; pulmonary hypertension due to cardiac disease; Eisenmenger's syndrome; or chronic obstructive pulmonary disease. Additional clinical requirements are that the beneficiary and caregiver are willing and capable of complying with the post-transplant treatment plan and that the beneficiary has adequate cardiac status. If the beneficiary is HIV-positive or has AIDS, the case must be evaluated individually and requires CD4 count greater than 200 cells/mm-3 for more than 6 months, undetectable HIV-1 RNA, stable antiretroviral therapy for more than 3 months, no other AIDS complications such as opportunistic infection or neoplasm, and meeting all other transplant criteria.
Place of Service
Acute inpatient hospital
How to Submit
Please submit your request to Carolina Complete Health
Resources
Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; unilateral
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health
Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilateral
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health
Resection of ribs, extrapleural, all stages
How to Submit
N/A - No authorization is required
Thoracoplasty, Schede type or extrapleural (all stages);
How to Submit
N/A - No authorization is required
Thoracoplasty, Schede type or extrapleural (all stages); with closure of bronchopleural fistula
How to Submit
N/A - No authorization is required
Pneumonolysis, extraperiosteal, including filling or packing procedures
How to Submit
N/A - No authorization is required
Pneumothorax, therapeutic, intrapleural injection of air
How to Submit
N/A - No authorization is required
Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation
How to Submit
N/A - No authorization is required
Total lung lavage (unilateral)
How to Submit
N/A - No authorization is required
Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; radiofrequency
How to Submit
N/A - No authorization is required
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.