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
Removal of embedded foreign body, vestibule of mouth; simple
Service Code
40804 (CPT) Removal of embedded foreign body, vestibule of mouth; simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Removal of embedded foreign body, vestibule of mouth; complicated
Service Code
40805 (CPT) Removal of embedded foreign body, vestibule of mouth; complicated
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Incision of labial frenum (frenotomy)
Service Code
40806 (CPT) Incision of labial frenum (frenotomy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Biopsy, vestibule of mouth
Service Code
40808 (CPT) Biopsy, vestibule of mouth
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair
Service Code
40810 (CPT) Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of lesion of mucosa and submucosa, vestibule of mouth; with simple repair
Service Code
40812 (CPT) Excision of lesion of mucosa and submucosa, vestibule of mouth; with simple repair
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair
Service Code
40814 (CPT) Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying muscle
Service Code
40816 (CPT) Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying muscle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of mucosa of vestibule of mouth as donor graft
Service Code
40818 (CPT) Excision of mucosa of vestibule of mouth as donor graft
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy)
Service Code
40819 (CPT) Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Destruction of lesion or scar of vestibule of mouth by physical methods (eg, laser, thermal, cryo, chemical)
Service Code
40820 (CPT) Destruction of lesion or scar of vestibule of mouth by physical methods (eg, laser, thermal, cryo, chemical)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of laceration, vestibule of mouth; 2.5 cm or less
Service Code
40830 (CPT) Closure of laceration, vestibule of mouth; 2.5 cm or less
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Closure of laceration, vestibule of mouth; over 2.5 cm or complex
Service Code
40831 (CPT) Closure of laceration, vestibule of mouth; over 2.5 cm or complex
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vestibuloplasty; anterior
Service Code
40840 (CPT) Vestibuloplasty; anterior
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vestibuloplasty; posterior, unilateral
Service Code
40842 (CPT) Vestibuloplasty; posterior, unilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vestibuloplasty; posterior, bilateral
Service Code
40843 (CPT) Vestibuloplasty; posterior, bilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vestibuloplasty; entire arch
Service Code
40844 (CPT) Vestibuloplasty; entire arch
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Vestibuloplasty; complex (including ridge extension, muscle repositioning)
Service Code
40845 (CPT) Vestibuloplasty; complex (including ridge extension, muscle repositioning)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted procedure, vestibule of mouth
Service Code
40899 (CPT) Unlisted procedure, vestibule of mouth
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
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual
Service Code
41000 (CPT) Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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