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Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12437 Results

Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine)

Service Code
64615 (CPT) Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)

Service Code
64616 (CPT) Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle electromyography, when performed

Service Code
64617 (CPT) Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle electromyography, when performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Destruction by neurolytic agent, intercostal nerve

Service Code
64620 (CPT) Destruction by neurolytic agent, intercostal nerve
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Pre-authorization is required for all providers unless performed on the same day as surgery. Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Trillium.

Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed

Service Code
64624 (CPT) Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Pre-authorization is required for all providers unless performed on the same day as surgery. Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Trillium.

Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)

Service Code
64625 (CPT) Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Pre-authorization is required for all providers unless performed on the same day as surgery. Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Trillium.

Destruction by neurolytic agent; pudendal nerve

Service Code
64630 (CPT) Destruction by neurolytic agent; pudendal nerve
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Pre-authorization is required for all providers unless performed on the same day as surgery. Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Trillium.

Destruction by neurolytic agent; plantar common digital nerve

Service Code
64632 (CPT) Destruction by neurolytic agent; plantar common digital nerve
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Pre-authorization is required for all providers unless performed on the same day as surgery. Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Trillium.

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

Service Code
64633 (CPT) Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Evolent site for specific requirements

Reauthorization Guidelines

See the Evolent site for specific requirements

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Evolent.

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

Service Code
64634 (CPT) Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Evolent site for specific requirements

Reauthorization Guidelines

See the Evolent site for specific requirements

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Evolent.

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint

Service Code
64635 (CPT) Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Evolent site for specific requirements

Reauthorization Guidelines

See the Evolent site for specific requirements

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Evolent.

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

Service Code
64636 (CPT) Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Evolent site for specific requirements

Reauthorization Guidelines

See the Evolent site for specific requirements

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Evolent.

Destruction by neurolytic agent; other peripheral nerve or branch

Service Code
64640 (CPT) Destruction by neurolytic agent; other peripheral nerve or branch
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Pre-authorization is required for all providers unless performed on the same day as surgery. Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Trillium.

Chemodenervation of one extremity; 1-4 muscle(s)

Service Code
64642 (CPT) Chemodenervation of one extremity; 1-4 muscle(s)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure)

Service Code
64643 (CPT) Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Chemodenervation of one extremity; 5 or more muscles

Service Code
64644 (CPT) Chemodenervation of one extremity; 5 or more muscles
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Chemodenervation of one extremity; each additional extremity, 5 or more muscles (List separately in addition to code for primary procedure)

Service Code
64645 (CPT) Chemodenervation of one extremity; each additional extremity, 5 or more muscles (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Chemodenervation of trunk muscle(s); 1-5 muscle(s)

Service Code
64646 (CPT) Chemodenervation of trunk muscle(s); 1-5 muscle(s)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Chemodenervation of trunk muscle(s); 6 or more muscles

Service Code
64647 (CPT) Chemodenervation of trunk muscle(s); 6 or more muscles
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Chemodenervation of eccrine glands; both axillae

Service Code
64650 (CPT) Chemodenervation of eccrine glands; both axillae
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Pre-authorization is required for all providers unless performed on the same day as surgery. Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

Pre-authorization is required for all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Trillium.