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12437 Results

Removal of implanted material, posterior segment; extraocular

Service Code
67120 (CPT) Removal of implanted material, posterior segment; extraocular
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal of implanted material, posterior segment; intraocular

Service Code
67121 (CPT) Removal of implanted material, posterior segment; intraocular
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, 1 or more sessions; cryotherapy, diathermy

Service Code
67141 (CPT) Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, 1 or more sessions; cryotherapy, diathermy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, 1 or more sessions; photocoagulation (laser or xenon arc)

Service Code
67145 (CPT) Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, 1 or more sessions; photocoagulation (laser or xenon arc)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; cryotherapy, diathermy

Service Code
67208 (CPT) Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; cryotherapy, diathermy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation

Service Code
67210 (CPT) Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; radiation by implantation of source (includes removal of source)

Service Code
67218 (CPT) Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; radiation by implantation of source (includes removal of source)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation (eg, laser), 1 or more sessions

Service Code
67220 (CPT) Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation (eg, laser), 1 or more sessions
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Ocular Photodynamic Therapy

Service Code
67221 (CPT) Destruction of localized lesion of choroid (eg, choroidal neovascularization); photodynamic therapy (includes intravenous infusion)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Ocular photodynamic therapy (OPT) is a treatment approved by the Food and Drug Administration for age-related macular degeneration (AMD), pathologic myopia, and ocular histoplasmosis. OPT is a two-step procedure involving the intravenous injection verteporfin (Visudyne®), a photosensitive drug. After injection, the verteporfin is activated by illumination with a non-thermal laser light at the wavelength that corresponds to the absorption peak of the drug. The light reacts with the photosensitive chemical in verteporfin, and the abnormal vessels are destroyed with no damage to the normal ones.

Limits

Beneficiaries may receive up to five treatments per eye per year with a maximum of ten treatments per eye during a 2-year-period.

Separate reimbursement is not allowed for intravenous infusion services.

Providers must maintain documentation including fluorescein angiogram and submit to NC Medicaid or its fiscal agent upon request.

Place of Service

Inpatient, Outpatient, Office

How to Submit

N/A - No authorization is required

Resources

Ocular Photodynamic Therapy

Service Code
67225 (CPT) Destruction of localized lesion of choroid (eg, choroidal neovascularization); photodynamic therapy, second eye, at single session (List separately in addition to code for primary eye treatment)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Ocular photodynamic therapy (OPT) is a treatment approved by the Food and Drug Administration for age-related macular degeneration (AMD), pathologic myopia, and ocular histoplasmosis. OPT is a two-step procedure involving the intravenous injection verteporfin (Visudyne®), a photosensitive drug. After injection, the verteporfin is activated by illumination with a non-thermal laser light at the wavelength that corresponds to the absorption peak of the drug. The light reacts with the photosensitive chemical in verteporfin, and the abnormal vessels are destroyed with no damage to the normal ones.

Limits

Beneficiaries may receive up to five treatments per eye per year with a maximum of ten treatments per eye during a 2-year-period.

Separate reimbursement is not allowed for intravenous infusion services.

Providers must maintain documentation including fluorescein angiogram and submit to NC Medicaid or its fiscal agent upon request.

Place of Service

Inpatient, Outpatient, Office

How to Submit

N/A - No authorization is required

Resources

Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), cryotherapy, diathermy

Service Code
67227 (CPT) Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), cryotherapy, diathermy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation

Service Code
67228 (CPT) Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Treatment of extensive or progressive retinopathy, 1 or more sessions, preterm infant (less than 37 weeks gestation at birth), performed from birth up to 1 year of age (eg, retinopathy of prematurity), photocoagulation or cryotherapy

Service Code
67229 (CPT) Treatment of extensive or progressive retinopathy, 1 or more sessions, preterm infant (less than 37 weeks gestation at birth), performed from birth up to 1 year of age (eg, retinopathy of prematurity), photocoagulation or cryotherapy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Scleral reinforcement (separate procedure); without graft

Service Code
67250 (CPT) Scleral reinforcement (separate procedure); without graft
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Scleral reinforcement (separate procedure); with graft

Service Code
67255 (CPT) Scleral reinforcement (separate procedure); with graft
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted procedure, posterior segment

Service Code
67299 (CPT) Unlisted procedure, posterior segment
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

Strabismus surgery, recession or resection procedure; 1 horizontal muscle

Service Code
67311 (CPT) Strabismus surgery, recession or resection procedure; 1 horizontal muscle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Strabismus surgery, recession or resection procedure; 2 horizontal muscles

Service Code
67312 (CPT) Strabismus surgery, recession or resection procedure; 2 horizontal muscles
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Strabismus surgery, recession or resection procedure; 1 vertical muscle (excluding superior oblique)

Service Code
67314 (CPT) Strabismus surgery, recession or resection procedure; 1 vertical muscle (excluding superior oblique)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Strabismus surgery, recession or resection procedure; 2 or more vertical muscles (excluding superior oblique)

Service Code
67316 (CPT) Strabismus surgery, recession or resection procedure; 2 or more vertical muscles (excluding superior oblique)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required