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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

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12465 Results

Glossectomy; less than one-half tongue

Service Code
41120 (CPT) Glossectomy; less than one-half tongue
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Glossectomy; hemiglossectomy

Service Code
41130 (CPT) Glossectomy; hemiglossectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Glossectomy; partial, with unilateral radical neck dissection

Service Code
41135 (CPT) Glossectomy; partial, with unilateral radical neck dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Glossectomy; complete or total, with or without tracheostomy, without radical neck dissection

Service Code
41140 (CPT) Glossectomy; complete or total, with or without tracheostomy, without radical neck dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Glossectomy; complete or total, with or without tracheostomy, with unilateral radical neck dissection

Service Code
41145 (CPT) Glossectomy; complete or total, with or without tracheostomy, with unilateral radical neck dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Glossectomy; composite procedure with resection floor of mouth and mandibular resection, without radical neck dissection

Service Code
41150 (CPT) Glossectomy; composite procedure with resection floor of mouth and mandibular resection, without radical neck dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Glossectomy; composite procedure with resection floor of mouth, with suprahyoid neck dissection

Service Code
41153 (CPT) Glossectomy; composite procedure with resection floor of mouth, with suprahyoid neck dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Glossectomy; composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection (Commando type)

Service Code
41155 (CPT) Glossectomy; composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection (Commando type)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue

Service Code
41250 (CPT) Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair of laceration 2.5 cm or less; posterior one-third of tongue

Service Code
41251 (CPT) Repair of laceration 2.5 cm or less; posterior one-third of tongue
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex

Service Code
41252 (CPT) Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Suture of tongue to lip for micrognathia (Douglas type procedure)

Service Code
41510 (CPT) Suture of tongue to lip for micrognathia (Douglas type procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tongue base suspension, permanent suture technique

Service Code
41512 (CPT) Tongue base suspension, permanent suture technique
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Surgery of the Lingual Frenulum

Service Code
41520 (CPT) Frenoplasty (surgical revision of frenum, eg, with Z-plasty)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Surgery of the lingual frenulum includes incision, excision, or surgical alteration of a short frenum to free the tongue and allow greater range of motion of the tongue.

Limits

Prior approval is required for beneficiaries 2 years of age and older. Surgery of the lingual frenulum is limited to once per lifetime.

Place of Service

Inpatient, Outpatient, Physician’s Office or Dental Office.

How to Submit

N/A - No authorization is required

Resources

Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session

Service Code
41530 (CPT) Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted procedure, tongue, floor of mouth

Service Code
41599 (CPT) Unlisted procedure, tongue, floor 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

Drainage of abscess, cyst, hematoma from dentoalveolar structures

Service Code
41800 (CPT) Drainage of abscess, cyst, hematoma from dentoalveolar structures
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 from dentoalveolar structures; soft tissues

Service Code
41805 (CPT) Removal of embedded foreign body from dentoalveolar structures; soft tissues
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 from dentoalveolar structures; bone

Service Code
41806 (CPT) Removal of embedded foreign body from dentoalveolar structures; bone
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Gingivectomy, excision gingiva, each quadrant

Service Code
41820 (CPT) Gingivectomy, excision gingiva, each quadrant
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required