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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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12437 Results

Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day

Service Code
64653 (CPT) Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day
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.

Removal of baroreflex activation therapy (BAT) modulation system; total system, including lead and pulse generator

Service Code
64657 (CPT) Removal of baroreflex activation therapy (BAT) modulation system; total system, including lead and pulse generator
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal of baroreflex activation therapy (BAT) modulation system; lead only

Service Code
64658 (CPT) Removal of baroreflex activation therapy (BAT) modulation system; lead only
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal of baroreflex activation therapy (BAT) modulation system; pulse generator only

Service Code
64659 (CPT) Removal of baroreflex activation therapy (BAT) modulation system; pulse generator only
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus

Service Code
64680 (CPT) Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus
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, with or without radiologic monitoring; superior hypogastric plexus

Service Code
64681 (CPT) Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric plexus
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.

Neuroplasty; digital, 1 or both, same digit

Service Code
64702 (CPT) Neuroplasty; digital, 1 or both, same digit
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Neuroplasty; nerve of hand or foot

Service Code
64704 (CPT) Neuroplasty; nerve of hand or foot
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Neuroplasty, major peripheral nerve, arm or leg, open; other than specified

Service Code
64708 (CPT) Neuroplasty, major peripheral nerve, arm or leg, open; other than specified
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Neuroplasty, major peripheral nerve, arm or leg, open; sciatic nerve

Service Code
64712 (CPT) Neuroplasty, major peripheral nerve, arm or leg, open; sciatic nerve
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Neuroplasty, major peripheral nerve, arm or leg, open; brachial plexus

Service Code
64713 (CPT) Neuroplasty, major peripheral nerve, arm or leg, open; brachial plexus
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Neuroplasty, major peripheral nerve, arm or leg, open; lumbar plexus

Service Code
64714 (CPT) Neuroplasty, major peripheral nerve, arm or leg, open; lumbar plexus
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Neuroplasty and/or transposition; cranial nerve (specify)

Service Code
64716 (CPT) Neuroplasty and/or transposition; cranial nerve (specify)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Neuroplasty and/or transposition; ulnar nerve at elbow

Service Code
64718 (CPT) Neuroplasty and/or transposition; ulnar nerve at elbow
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Neuroplasty and/or transposition; ulnar nerve at wrist

Service Code
64719 (CPT) Neuroplasty and/or transposition; ulnar nerve at wrist
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Neuroplasty and/or transposition; median nerve at carpal tunnel

Service Code
64721 (CPT) Neuroplasty and/or transposition; median nerve at carpal tunnel
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Decompression; unspecified nerve(s) (specify)

Service Code
64722 (CPT) Decompression; unspecified nerve(s) (specify)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Decompression; plantar digital nerve

Service Code
64726 (CPT) Decompression; plantar digital nerve
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis)

Service Code
64727 (CPT) Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Transection or avulsion of; supraorbital nerve

Service Code
64732 (CPT) Transection or avulsion of; supraorbital nerve
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required