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
Resection, diaphragm; with complex repair (eg, prosthetic material, local muscle flap)
Service Code
39561 (CPT) Resection, diaphragm; with complex repair (eg, prosthetic material, local muscle flap)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted procedure, diaphragm
Service Code
39599 (CPT) Unlisted procedure, diaphragm
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
Biopsy of lip
Service Code
40490 (CPT) Biopsy of lip
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vermilionectomy (lip shave), with mucosal advancement
Service Code
40500 (CPT) Vermilionectomy (lip shave), with mucosal advancement
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of lip; transverse wedge excision with primary closure
Service Code
40510 (CPT) Excision of lip; transverse wedge excision with primary closure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of lip; V-excision with primary direct linear closure
Service Code
40520 (CPT) Excision of lip; V-excision with primary direct linear closure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of lip; full thickness, reconstruction with local flap (eg, Estlander or fan)
Service Code
40525 (CPT) Excision of lip; full thickness, reconstruction with local flap (eg, Estlander or fan)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of lip; full thickness, reconstruction with cross lip flap (Abbe-Estlander)
Service Code
40527 (CPT) Excision of lip; full thickness, reconstruction with cross lip flap (Abbe-Estlander)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Resection of lip, more than one-fourth, without reconstruction
Service Code
40530 (CPT) Resection of lip, more than one-fourth, without reconstruction
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair lip, full thickness; vermilion only
Service Code
40650 (CPT) Repair lip, full thickness; vermilion only
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair lip, full thickness; up to half vertical height
Service Code
40652 (CPT) Repair lip, full thickness; up to half vertical height
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair lip, full thickness; over one-half vertical height, or complex
Service Code
40654 (CPT) Repair lip, full thickness; over one-half vertical height, or complex
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral
Service Code
40700 (CPT) Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Plastic repair of cleft lip/nasal deformity; primary bilateral, 1-stage procedure
Service Code
40701 (CPT) Plastic repair of cleft lip/nasal deformity; primary bilateral, 1-stage procedure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 stages
Service Code
40702 (CPT) Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 stages
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure
Service Code
40720 (CPT) Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle
Service Code
40761 (CPT) Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted procedure, lips
Service Code
40799 (CPT) Unlisted procedure, lips
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
Drainage of abscess, cyst, hematoma, vestibule of mouth; simple
Service Code
40800 (CPT) Drainage of abscess, cyst, hematoma, vestibule of mouth; simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated
Service Code
40801 (CPT) Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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