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
Operculectomy, excision pericoronal tissues
Service Code
41821 (CPT) Operculectomy, excision pericoronal tissues
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of fibrous tuberosities, dentoalveolar structures
Service Code
41822 (CPT) Excision of fibrous tuberosities, dentoalveolar structures
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of osseous tuberosities, dentoalveolar structures
Service Code
41823 (CPT) Excision of osseous tuberosities, dentoalveolar structures
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair
Service Code
41825 (CPT) Excision of lesion or tumor (except listed above), dentoalveolar structures; 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 or tumor (except listed above), dentoalveolar structures; with simple repair
Service Code
41826 (CPT) Excision of lesion or tumor (except listed above), dentoalveolar structures; 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 or tumor (except listed above), dentoalveolar structures; with complex repair
Service Code
41827 (CPT) Excision of lesion or tumor (except listed above), dentoalveolar structures; 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 hyperplastic alveolar mucosa, each quadrant (specify)
Service Code
41828 (CPT) Excision of hyperplastic alveolar mucosa, each quadrant (specify)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Alveolectomy, including curettage of osteitis or sequestrectomy
Service Code
41830 (CPT) Alveolectomy, including curettage of osteitis or sequestrectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Destruction of lesion (except excision), dentoalveolar structures
Service Code
41850 (CPT) Destruction of lesion (except excision), dentoalveolar structures
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Periodontal mucosal grafting
Service Code
41870 (CPT) Periodontal mucosal grafting
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Gingivoplasty, each quadrant (specify)
Service Code
41872 (CPT) Gingivoplasty, each quadrant (specify)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Alveoloplasty, each quadrant (specify)
Service Code
41874 (CPT) Alveoloplasty, each quadrant (specify)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted procedure, dentoalveolar structures
Service Code
41899 (CPT) Unlisted procedure, dentoalveolar structures
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 of palate, uvula
Service Code
42000 (CPT) Drainage of abscess of palate, uvula
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Biopsy of palate, uvula
Service Code
42100 (CPT) Biopsy of palate, uvula
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision, lesion of palate, uvula; without closure
Service Code
42104 (CPT) Excision, lesion of palate, uvula; without closure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision, lesion of palate, uvula; with simple primary closure
Service Code
42106 (CPT) Excision, lesion of palate, uvula; with simple primary closure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision, lesion of palate, uvula; with local flap closure
Service Code
42107 (CPT) Excision, lesion of palate, uvula; with local flap closure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Resection of palate or extensive resection of lesion
Service Code
42120 (CPT) Resection of palate or extensive resection of lesion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Uvulectomy, excision of uvula
Service Code
42140 (CPT) Uvulectomy, excision of uvula
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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