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Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12437 Results

Correction of trichiasis; incision of lid margin, with free mucous membrane graft

Service Code
67835 (CPT) Correction of trichiasis; incision of lid margin, with free mucous membrane graft
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure

Service Code
67840 (CPT) Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Destruction of lesion of lid margin (up to 1 cm)

Service Code
67850 (CPT) Destruction of lesion of lid margin (up to 1 cm)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Temporary closure of eyelids by suture (eg, Frost suture)

Service Code
67875 (CPT) Temporary closure of eyelids by suture (eg, Frost suture)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy;

Service Code
67880 (CPT) Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; with transposition of tarsal plate

Service Code
67882 (CPT) Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; with transposition of tarsal plate
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

Service Code
67900 (CPT) Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
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

Blepharoplasty and Blepharoptosis Eyelid Repair

Service Code
67901 (CPT) Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Blepharoplasty and blepharoptosis eyelid repair are reconstructive plastic surgery procedures of the eyelids. Surgery of the upper eyelids is reconstructive when it provides functional vision or visual field benefits or improves the functioning of a malformed or degenerated body member. The goal of reconstructive surgery is to restore function to the eye structure.

Authorization Guidelines

The provider(s) shall submit the following:

  • a. the prior approval request; and
  • b. all health records and any other records that support the beneficiary has met

the specific criteria in Subsection 3.2.1 of this policy.

Exclusions

Medicaid shall not cover blepharoplasty and blepharoptosis eyelid repair performed solely for cosmetic reasons to enhance aesthetic appearance.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Blepharoplasty and Blepharoptosis Eyelid Repair

Service Code
67902 (CPT) Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Blepharoplasty and blepharoptosis eyelid repair are reconstructive plastic surgery procedures of the eyelids. Surgery of the upper eyelids is reconstructive when it provides functional vision or visual field benefits or improves the functioning of a malformed or degenerated body member. The goal of reconstructive surgery is to restore function to the eye structure.

Authorization Guidelines

In addition to the general requirements , providers are also required to submit the following: a. medical documentation that the eyelid ptosis obstructs vision including visual field examination results, unless the beneficiary is unable to test; b. medical documentation that the beneficiary has exposure keratitis of the lower eyelid; or c. medical documentation to substantiate medical necessity for surgery including the following:

  • 1. beneficiary complaints of interference with vision or visual fields,

difficulty reading due to eyelid drooping, looking through eyelashes, or seeing upper eyelid skin;

  • 2. relevant medical history;
  • 3. physical examination findings; and
  • 4. results of pertinent diagnostic tests or procedures

Exclusions

Medicaid shall not cover blepharoplasty and blepharoptosis eyelid repair performed solely for cosmetic reasons to enhance aesthetic appearance.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Blepharoplasty and Blepharoptosis Eyelid Repair

Service Code
67903 (CPT) Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Blepharoplasty and blepharoptosis eyelid repair are reconstructive plastic surgery procedures of the eyelids. Surgery of the upper eyelids is reconstructive when it provides functional vision or visual field benefits or improves the functioning of a malformed or degenerated body member. The goal of reconstructive surgery is to restore function to the eye structure.

Authorization Guidelines

In addition to the general requirements , providers are also required to submit the following: a. medical documentation that the eyelid ptosis obstructs vision including visual field examination results, unless the beneficiary is unable to test; b. medical documentation that the beneficiary has exposure keratitis of the lower eyelid; or c. medical documentation to substantiate medical necessity for surgery including the following:

  • 1. beneficiary complaints of interference with vision or visual fields,

difficulty reading due to eyelid drooping, looking through eyelashes, or seeing upper eyelid skin;

  • 2. relevant medical history;
  • 3. physical examination findings; and
  • 4. results of pertinent diagnostic tests or procedures

Exclusions

Medicaid shall not cover blepharoplasty and blepharoptosis eyelid repair performed solely for cosmetic reasons to enhance aesthetic appearance.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Blepharoplasty and Blepharoptosis Eyelid Repair

Service Code
67904 (CPT) Repair of blepharoptosis; (tarso) levator resection or advancement, external approach
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Blepharoplasty and blepharoptosis eyelid repair are reconstructive plastic surgery procedures of the eyelids. Surgery of the upper eyelids is reconstructive when it provides functional vision or visual field benefits or improves the functioning of a malformed or degenerated body member. The goal of reconstructive surgery is to restore function to the eye structure.

Authorization Guidelines

In addition to the general requirements , providers are also required to submit the following: a. medical documentation that the eyelid ptosis obstructs vision including visual field examination results, unless the beneficiary is unable to test; b. medical documentation that the beneficiary has exposure keratitis of the lower eyelid; or c. medical documentation to substantiate medical necessity for surgery including the following:

  • 1. beneficiary complaints of interference with vision or visual fields,

difficulty reading due to eyelid drooping, looking through eyelashes, or seeing upper eyelid skin;

  • 2. relevant medical history;
  • 3. physical examination findings; and
  • 4. results of pertinent diagnostic tests or procedures

Exclusions

Medicaid shall not cover blepharoplasty and blepharoptosis eyelid repair performed solely for cosmetic reasons to enhance aesthetic appearance.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Blepharoplasty and Blepharoptosis Eyelid Repair

Service Code
67906 (CPT) Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Blepharoplasty and blepharoptosis eyelid repair are reconstructive plastic surgery procedures of the eyelids. Surgery of the upper eyelids is reconstructive when it provides functional vision or visual field benefits or improves the functioning of a malformed or degenerated body member. The goal of reconstructive surgery is to restore function to the eye structure.

Authorization Guidelines

In addition to the general requirements , providers are also required to submit the following: a. medical documentation that the eyelid ptosis obstructs vision including visual field examination results, unless the beneficiary is unable to test; b. medical documentation that the beneficiary has exposure keratitis of the lower eyelid; or c. medical documentation to substantiate medical necessity for surgery including the following:

  • 1. beneficiary complaints of interference with vision or visual fields,

difficulty reading due to eyelid drooping, looking through eyelashes, or seeing upper eyelid skin;

  • 2. relevant medical history;
  • 3. physical examination findings; and
  • 4. results of pertinent diagnostic tests or procedures

Exclusions

Medicaid shall not cover blepharoplasty and blepharoptosis eyelid repair performed solely for cosmetic reasons to enhance aesthetic appearance.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Blepharoplasty and Blepharoptosis Eyelid Repair

Service Code
67908 (CPT) Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Blepharoplasty and blepharoptosis eyelid repair are reconstructive plastic surgery procedures of the eyelids. Surgery of the upper eyelids is reconstructive when it provides functional vision or visual field benefits or improves the functioning of a malformed or degenerated body member. The goal of reconstructive surgery is to restore function to the eye structure.

Authorization Guidelines

In addition to the general requirements , providers are also required to submit the following: a. medical documentation that the eyelid ptosis obstructs vision including visual field examination results, unless the beneficiary is unable to test; b. medical documentation that the beneficiary has exposure keratitis of the lower eyelid; or c. medical documentation to substantiate medical necessity for surgery including the following:

  • 1. beneficiary complaints of interference with vision or visual fields,

difficulty reading due to eyelid drooping, looking through eyelashes, or seeing upper eyelid skin;

  • 2. relevant medical history;
  • 3. physical examination findings; and
  • 4. results of pertinent diagnostic tests or procedures

Exclusions

Medicaid shall not cover blepharoplasty and blepharoptosis eyelid repair performed solely for cosmetic reasons to enhance aesthetic appearance.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Blepharoplasty and Blepharoptosis Eyelid Repair

Service Code
67909 (CPT) Reduction of overcorrection of ptosis
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Blepharoplasty and blepharoptosis eyelid repair are reconstructive plastic surgery procedures of the eyelids. Surgery of the upper eyelids is reconstructive when it provides functional vision or visual field benefits or improves the functioning of a malformed or degenerated body member. The goal of reconstructive surgery is to restore function to the eye structure.

Authorization Guidelines

In addition to the general requirements , providers are also required to submit the following: a. medical documentation that the eyelid ptosis obstructs vision including visual field examination results, unless the beneficiary is unable to test; b. medical documentation that the beneficiary has exposure keratitis of the lower eyelid; or c. medical documentation to substantiate medical necessity for surgery including the following:

  • 1. beneficiary complaints of interference with vision or visual fields,

difficulty reading due to eyelid drooping, looking through eyelashes, or seeing upper eyelid skin;

  • 2. relevant medical history;
  • 3. physical examination findings; and
  • 4. results of pertinent diagnostic tests or procedures

Exclusions

Medicaid shall not cover blepharoplasty and blepharoptosis eyelid repair performed solely for cosmetic reasons to enhance aesthetic appearance.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Blepharoplasty and Blepharoptosis Eyelid Repair

Service Code
67911 (CPT) Correction of lid retraction
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Blepharoplasty and blepharoptosis eyelid repair are reconstructive plastic surgery procedures of the eyelids. Surgery of the upper eyelids is reconstructive when it provides functional vision or visual field benefits or improves the functioning of a malformed or degenerated body member. The goal of reconstructive surgery is to restore function to the eye structure.

Authorization Guidelines

In addition to the general requirements , providers are also required to submit the following: a. medical documentation that the eyelid ptosis obstructs vision including visual field examination results, unless the beneficiary is unable to test; b. medical documentation that the beneficiary has exposure keratitis of the lower eyelid; or c. medical documentation to substantiate medical necessity for surgery including the following:

  • 1. beneficiary complaints of interference with vision or visual fields,

difficulty reading due to eyelid drooping, looking through eyelashes, or seeing upper eyelid skin;

  • 2. relevant medical history;
  • 3. physical examination findings; and
  • 4. results of pertinent diagnostic tests or procedures

Exclusions

Medicaid shall not cover blepharoplasty and blepharoptosis eyelid repair performed solely for cosmetic reasons to enhance aesthetic appearance.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Correction of lagophthalmos, with implantation of upper eyelid lid load (eg, gold weight)

Service Code
67912 (CPT) Correction of lagophthalmos, with implantation of upper eyelid lid load (eg, gold weight)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair of ectropion; suture

Service Code
67914 (CPT) Repair of ectropion; suture
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair of ectropion; thermocauterization

Service Code
67915 (CPT) Repair of ectropion; thermocauterization
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair of ectropion; excision tarsal wedge

Service Code
67916 (CPT) Repair of ectropion; excision tarsal wedge
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair of ectropion; extensive (eg, tarsal strip operations)

Service Code
67917 (CPT) Repair of ectropion; extensive (eg, tarsal strip operations)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required