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

Filter By:
Clear Filters
12437 Results

Otoplasty, protruding ear, with or without size reduction

Service Code
69300 (CPT) Otoplasty, protruding ear, with or without size reduction
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

Reconstruction of external auditory canal (meatoplasty) (eg, for stenosis due to injury, infection) (separate procedure)

Service Code
69310 (CPT) Reconstruction of external auditory canal (meatoplasty) (eg, for stenosis due to injury, infection) (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Reconstruction external auditory canal for congenital atresia, single stage

Service Code
69320 (CPT) Reconstruction external auditory canal for congenital atresia, single stage
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted procedure, external ear

Service Code
69399 (CPT) Unlisted procedure, external ear
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

Myringotomy including aspiration and/or eustachian tube inflation

Service Code
69420 (CPT) Myringotomy including aspiration and/or eustachian tube inflation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia

Service Code
69421 (CPT) Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Ventilating tube removal requiring general anesthesia

Service Code
69424 (CPT) Ventilating tube removal requiring general anesthesia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia

Service Code
69433 (CPT) Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tympanostomy (requiring insertion of ventilating tube), general anesthesia

Service Code
69436 (CPT) Tympanostomy (requiring insertion of ventilating tube), general anesthesia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Middle ear exploration through postauricular or ear canal incision

Service Code
69440 (CPT) Middle ear exploration through postauricular or ear canal incision
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tympanolysis, transcanal

Service Code
69450 (CPT) Tympanolysis, transcanal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Transmastoid antrotomy (simple mastoidectomy)

Service Code
69501 (CPT) Transmastoid antrotomy (simple mastoidectomy)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Mastoidectomy; complete

Service Code
69502 (CPT) Mastoidectomy; complete
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Mastoidectomy; modified radical

Service Code
69505 (CPT) Mastoidectomy; modified radical
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Mastoidectomy; radical

Service Code
69511 (CPT) Mastoidectomy; radical
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Petrous apicectomy including radical mastoidectomy

Service Code
69530 (CPT) Petrous apicectomy including radical mastoidectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Resection temporal bone, external approach

Service Code
69535 (CPT) Resection temporal bone, external approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision aural polyp

Service Code
69540 (CPT) Excision aural polyp
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision aural glomus tumor; transcanal

Service Code
69550 (CPT) Excision aural glomus tumor; transcanal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision aural glomus tumor; transmastoid

Service Code
69552 (CPT) Excision aural glomus tumor; transmastoid
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required