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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

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12437 Results

Injection of contrast medium for dacryocystography

Service Code
68850 (CPT) Injection of contrast medium for dacryocystography
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted procedure, lacrimal system

Service Code
68899 (CPT) Unlisted procedure, lacrimal system
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

Drainage external ear, abscess or hematoma; simple

Service Code
69000 (CPT) Drainage external ear, abscess or hematoma; simple
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Drainage external ear, abscess or hematoma; complicated

Service Code
69005 (CPT) Drainage external ear, abscess or hematoma; complicated
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Drainage external auditory canal, abscess

Service Code
69020 (CPT) Drainage external auditory canal, abscess
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Ear piercing

Service Code
69090 (CPT) Ear piercing
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Biopsy external ear

Service Code
69100 (CPT) Biopsy external ear
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Biopsy external auditory canal

Service Code
69105 (CPT) Biopsy external auditory canal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision external ear; partial, simple repair

Service Code
69110 (CPT) Excision external ear; partial, simple repair
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision external ear; complete amputation

Service Code
69120 (CPT) Excision external ear; complete amputation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision exostosis(es), external auditory canal

Service Code
69140 (CPT) Excision exostosis(es), external auditory canal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision soft tissue lesion, external auditory canal

Service Code
69145 (CPT) Excision soft tissue lesion, external auditory canal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Radical excision external auditory canal lesion; without neck dissection

Service Code
69150 (CPT) Radical excision external auditory canal lesion; without neck dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Radical excision external auditory canal lesion; with neck dissection

Service Code
69155 (CPT) Radical excision external auditory canal lesion; with neck dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal foreign body from external auditory canal; without general anesthesia

Service Code
69200 (CPT) Removal foreign body from external auditory canal; without general anesthesia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal foreign body from external auditory canal; with general anesthesia

Service Code
69205 (CPT) Removal foreign body from external auditory canal; with general anesthesia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal impacted cerumen using irrigation/lavage, unilateral

Service Code
69209 (CPT) Removal impacted cerumen using irrigation/lavage, unilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tympanometry and Acoustic Reflex Testing

Service Code
69210 (CPT) Removal impacted cerumen requiring instrumentation, unilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Tympanometry and acoustic reflex testing both provide valuable information when evaluating the middle ear and inner ear respectively. However, each test has its own specific function. Tympanometry provides useful quantitative information about the presence of fluid in the middle ear. This is a useful study for pediatricians, family practitioners, and otolaryngologists as it can be used for determining middle ear disease and, is excellent for following children with a history of middle ear disease. It is the only method of measuring middle ear function in a beneficiary who is unable to perform a formal audiometry test. Tympanometry is usually indicated without acoustic reflex testing. Acoustic reflex testing utilizes sound to test the reflex contractions of the stapedius muscle. This may be measured bilaterally, even when the sound is introduced only on one side. This test is used specifically for the evaluation of sensorineural hearing loss.

Exclusions

Medicaid will not cover the following:

  • a. Tympanometry and acoustic reflex testing for routine screenings.
  • b. Tympanometry and acoustic reflex testing for a beneficiary who does not

meet any of the indications listed in Subsection 3.2.1.

  • c. Tympanometry when any of the following are present:
  • 1. Ear pain;
  • 2. Decreased hearing when no objective hearing test performed;
  • 3. Ear drainage;
  • 4. Fever;
  • 5. Inflamed tympanic membrane;
  • 6. Desquamated epithelium on membrane;
  • 7. Bulging tympanic membrane; or
  • 8. Evidence of middle ear effusion

Place of Service

Inpatient, Outpatient, Office

How to Submit

N/A - No authorization is required

Resources

Debridement, mastoidectomy cavity, simple (eg, routine cleaning)

Service Code
69220 (CPT) Debridement, mastoidectomy cavity, simple (eg, routine cleaning)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine cleaning)

Service Code
69222 (CPT) Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine cleaning)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required