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

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12465 Results

Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Service Code
42145 (CPT) Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)
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

Destruction of lesion, palate or uvula (thermal, cryo or chemical)

Service Code
42160 (CPT) Destruction of lesion, palate or uvula (thermal, cryo or chemical)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair, laceration of palate; up to 2 cm

Service Code
42180 (CPT) Repair, laceration of palate; up to 2 cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair, laceration of palate; over 2 cm or complex

Service Code
42182 (CPT) Repair, laceration of palate; over 2 cm or complex
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Palatoplasty for cleft palate, soft and/or hard palate only

Service Code
42200 (CPT) Palatoplasty for cleft palate, soft and/or hard palate only
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only

Service Code
42205 (CPT) Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Palatoplasty for cleft palate, with closure of alveolar ridge; with bone graft to alveolar ridge (includes obtaining graft)

Service Code
42210 (CPT) Palatoplasty for cleft palate, with closure of alveolar ridge; with bone graft to alveolar ridge (includes obtaining graft)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Palatoplasty for cleft palate; major revision

Service Code
42215 (CPT) Palatoplasty for cleft palate; major revision
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Palatoplasty for cleft palate; secondary lengthening procedure

Service Code
42220 (CPT) Palatoplasty for cleft palate; secondary lengthening procedure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Palatoplasty for cleft palate; attachment pharyngeal flap

Service Code
42225 (CPT) Palatoplasty for cleft palate; attachment pharyngeal flap
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Lengthening of palate, and pharyngeal flap

Service Code
42226 (CPT) Lengthening of palate, and pharyngeal flap
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Lengthening of palate, with island flap

Service Code
42227 (CPT) Lengthening of palate, with island flap
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair of anterior palate, including vomer flap

Service Code
42235 (CPT) Repair of anterior palate, including vomer flap
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair of nasolabial fistula

Service Code
42260 (CPT) Repair of nasolabial fistula
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Maxillary impression for palatal prosthesis

Service Code
42280 (CPT) Maxillary impression for palatal prosthesis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Insertion of pin-retained palatal prosthesis

Service Code
42281 (CPT) Insertion of pin-retained palatal prosthesis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted procedure, palate, uvula

Service Code
42299 (CPT) Unlisted procedure, palate, uvula
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; parotid, simple

Service Code
42300 (CPT) Drainage of abscess; parotid, simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Drainage of abscess; parotid, complicated

Service Code
42305 (CPT) Drainage of abscess; parotid, complicated
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Drainage of abscess; submaxillary or sublingual, intraoral

Service Code
42310 (CPT) Drainage of abscess; submaxillary or sublingual, intraoral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required