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
12437 Results
Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; more than 4 cm length
Service Code
64896 (CPT) Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; more than 4 cm length
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; up to 4 cm length
Service Code
64897 (CPT) Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; up to 4 cm length
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; more than 4 cm length
Service Code
64898 (CPT) Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; more than 4 cm length
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve graft, each additional nerve; single strand (List separately in addition to code for primary procedure)
Service Code
64901 (CPT) Nerve graft, each additional nerve; single strand (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
Nerve graft, each additional nerve; multiple strands (cable) (List separately in addition to code for primary procedure)
Service Code
64902 (CPT) Nerve graft, each additional nerve; multiple strands (cable) (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
Nerve pedicle transfer; first stage
Service Code
64905 (CPT) Nerve pedicle transfer; first stage
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve pedicle transfer; second stage
Service Code
64907 (CPT) Nerve pedicle transfer; second stage
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve repair; with synthetic conduit or vein allograft (eg, nerve tube), each nerve
Service Code
64910 (CPT) Nerve repair; with synthetic conduit or vein allograft (eg, nerve tube), each nerve
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve repair; with autogenous vein graft (includes harvest of vein graft), each nerve
Service Code
64911 (CPT) Nerve repair; with autogenous vein graft (includes harvest of vein graft), each nerve
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve repair; with nerve allograft, each nerve, first strand (cable)
Service Code
64912 (CPT) Nerve repair; with nerve allograft, each nerve, first strand (cable)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nerve repair; with nerve allograft, each additional strand (List separately in addition to code for primary procedure)
Service Code
64913 (CPT) Nerve repair; with nerve allograft, each additional strand (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
Unlisted procedure, nervous system
Service Code
64999 (CPT) Unlisted procedure, nervous system
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
Evisceration of ocular contents; without implant
Service Code
65091 (CPT) Evisceration of ocular contents; without implant
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Evisceration of ocular contents; with implant
Service Code
65093 (CPT) Evisceration of ocular contents; with implant
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Enucleation of eye; without implant
Service Code
65101 (CPT) Enucleation of eye; without implant
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Enucleation of eye; with implant, muscles not attached to implant
Service Code
65103 (CPT) Enucleation of eye; with implant, muscles not attached to implant
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Enucleation of eye; with implant, muscles attached to implant
Service Code
65105 (CPT) Enucleation of eye; with implant, muscles attached to implant
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Exenteration of orbit (does not include skin graft), removal of orbital contents; only
Service Code
65110 (CPT) Exenteration of orbit (does not include skin graft), removal of orbital contents; only
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Exenteration of orbit (does not include skin graft), removal of orbital contents; with therapeutic removal of bone
Service Code
65112 (CPT) Exenteration of orbit (does not include skin graft), removal of orbital contents; with therapeutic removal of bone
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Exenteration of orbit (does not include skin graft), removal of orbital contents; with muscle or myocutaneous flap
Service Code
65114 (CPT) Exenteration of orbit (does not include skin graft), removal of orbital contents; with muscle or myocutaneous flap
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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