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
Repair of laceration; application of tissue glue, wounds of cornea and/or sclera
Service Code
65286 (CPT) Repair of laceration; application of tissue glue, wounds of cornea and/or sclera
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Repair of wound, extraocular muscle, tendon and/or Tenon's capsule
Service Code
65290 (CPT) Repair of wound, extraocular muscle, tendon and/or Tenon's capsule
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium
Service Code
65400 (CPT) Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Biopsy of cornea
Service Code
65410 (CPT) Biopsy of cornea
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision or transposition of pterygium; without graft
Service Code
65420 (CPT) Excision or transposition of pterygium; without graft
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision or transposition of pterygium; with graft
Service Code
65426 (CPT) Excision or transposition of pterygium; with graft
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Scraping of cornea, diagnostic, for smear and/or culture
Service Code
65430 (CPT) Scraping of cornea, diagnostic, for smear and/or culture
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage)
Service Code
65435 (CPT) Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Removal of corneal epithelium; with application of chelating agent (eg, EDTA)
Service Code
65436 (CPT) Removal of corneal epithelium; with application of chelating agent (eg, EDTA)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization
Service Code
65450 (CPT) Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Multiple punctures of anterior cornea (eg, for corneal erosion, tattoo)
Service Code
65600 (CPT) Multiple punctures of anterior cornea (eg, for corneal erosion, tattoo)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Keratoplasty (corneal transplant); anterior lamellar
Service Code
65710 (CPT) Keratoplasty (corneal transplant); anterior lamellar
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia)
Service Code
65730 (CPT) Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Keratoplasty (corneal transplant); penetrating (in aphakia)
Service Code
65750 (CPT) Keratoplasty (corneal transplant); penetrating (in aphakia)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Keratoplasty (corneal transplant); penetrating (in pseudophakia)
Service Code
65755 (CPT) Keratoplasty (corneal transplant); penetrating (in pseudophakia)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Keratoplasty (corneal transplant); endothelial
Service Code
65756 (CPT) Keratoplasty (corneal transplant); endothelial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Backbench preparation of corneal endothelial allograft prior to transplantation (List separately in addition to code for primary procedure)
Service Code
65757 (CPT) Backbench preparation of corneal endothelial allograft prior to transplantation (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
Keratomileusis
Service Code
65760 (CPT) Keratomileusis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Keratophakia
Service Code
65765 (CPT) Keratophakia
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
Epikeratoplasty
Service Code
65767 (CPT) Epikeratoplasty
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
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