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
Strabismus surgery, any procedure, superior oblique muscle
Service Code
67318 (CPT) Strabismus surgery, any procedure, superior oblique muscle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Transposition procedure (eg, for paretic extraocular muscle), any extraocular muscle (specify) (List separately in addition to code for primary procedure)
Service Code
67320 (CPT) Transposition procedure (eg, for paretic extraocular muscle), any extraocular muscle (specify) (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
Strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular muscles (List separately in addition to code for primary procedure)
Service Code
67331 (CPT) Strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular 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
Strabismus surgery on patient with scarring of extraocular muscles (eg, prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (eg, dysthyroid ophthalmopathy) (List separately in addition to code for primary procedure)
Service Code
67332 (CPT) Strabismus surgery on patient with scarring of extraocular muscles (eg, prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (eg, dysthyroid ophthalmopathy) (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
Strabismus surgery by posterior fixation suture technique, with or without muscle recession (List separately in addition to code for primary procedure)
Service Code
67334 (CPT) Strabismus surgery by posterior fixation suture technique, with or without muscle recession (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
Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s) (List separately in addition to code for specific strabismus surgery)
Service Code
67335 (CPT) Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s) (List separately in addition to code for specific strabismus surgery)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) (List separately in addition to code for primary procedure)
Service Code
67340 (CPT) Strabismus surgery involving exploration and/or repair of detached extraocular 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
Release of extensive scar tissue without detaching extraocular muscle (separate procedure)
Service Code
67343 (CPT) Release of extensive scar tissue without detaching extraocular muscle (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Chemodenervation of extraocular muscle
Service Code
67345 (CPT) Chemodenervation of extraocular muscle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Biopsy of extraocular muscle
Service Code
67346 (CPT) Biopsy of extraocular muscle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted procedure, extraocular muscle
Service Code
67399 (CPT) Unlisted procedure, extraocular muscle
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
Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy
Service Code
67400 (CPT) Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Orbitotomy without bone flap (frontal or transconjunctival approach); with drainage only
Service Code
67405 (CPT) Orbitotomy without bone flap (frontal or transconjunctival approach); with drainage only
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of lesion
Service Code
67412 (CPT) Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of lesion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of foreign body
Service Code
67413 (CPT) Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of foreign body
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of bone for decompression
Service Code
67414 (CPT) Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of bone for decompression
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Fine needle aspiration of orbital contents
Service Code
67415 (CPT) Fine needle aspiration of orbital contents
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of lesion
Service Code
67420 (CPT) Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of lesion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of foreign body
Service Code
67430 (CPT) Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of foreign body
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with drainage
Service Code
67440 (CPT) Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with drainage
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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