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
Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of bone for decompression
Service Code
67445 (CPT) Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); 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
Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); for exploration, with or without biopsy
Service Code
67450 (CPT) Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); 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
Retrobulbar injection; medication (separate procedure, does not include supply of medication)
Service Code
67500 (CPT) Retrobulbar injection; medication (separate procedure, does not include supply of medication)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Retrobulbar injection; alcohol
Service Code
67505 (CPT) Retrobulbar injection; alcohol
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Injection of medication or other substance into Tenon's capsule
Service Code
67515 (CPT) Injection of medication or other substance into Tenon's capsule
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Orbital implant (implant outside muscle cone); insertion
Service Code
67550 (CPT) Orbital implant (implant outside muscle cone); insertion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Orbital implant (implant outside muscle cone); removal or revision
Service Code
67560 (CPT) Orbital implant (implant outside muscle cone); removal or revision
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Optic nerve decompression (eg, incision or fenestration of optic nerve sheath)
Service Code
67570 (CPT) Optic nerve decompression (eg, incision or fenestration of optic nerve sheath)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted procedure, orbit
Service Code
67599 (CPT) Unlisted procedure, orbit
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
Blepharotomy, drainage of abscess, eyelid
Service Code
67700 (CPT) Blepharotomy, drainage of abscess, eyelid
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Severing of tarsorrhaphy
Service Code
67710 (CPT) Severing of tarsorrhaphy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Canthotomy (separate procedure)
Service Code
67715 (CPT) Canthotomy (separate procedure)
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
Excision of chalazion; single
Service Code
67800 (CPT) Excision of chalazion; single
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of chalazion; multiple, same lid
Service Code
67801 (CPT) Excision of chalazion; multiple, same lid
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of chalazion; multiple, different lids
Service Code
67805 (CPT) Excision of chalazion; multiple, different lids
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Excision of chalazion; under general anesthesia and/or requiring hospitalization, single or multiple
Service Code
67808 (CPT) Excision of chalazion; under general anesthesia and/or requiring hospitalization, single or multiple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Incisional biopsy of eyelid skin including lid margin
Service Code
67810 (CPT) Incisional biopsy of eyelid skin including lid margin
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Correction of trichiasis; epilation, by forceps only
Service Code
67820 (CPT) Correction of trichiasis; epilation, by forceps only
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Correction of trichiasis; epilation by other than forceps (eg, by electrosurgery, cryotherapy, laser surgery)
Service Code
67825 (CPT) Correction of trichiasis; epilation by other than forceps (eg, by electrosurgery, cryotherapy, laser surgery)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Correction of trichiasis; incision of lid margin
Service Code
67830 (CPT) Correction of trichiasis; incision of lid margin
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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