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

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12437 Results

Suture facial nerve, intratemporal, with or without graft or decompression; lateral to geniculate ganglion

Service Code
69740 (CPT) Suture facial nerve, intratemporal, with or without graft or decompression; lateral to geniculate ganglion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Suture facial nerve, intratemporal, with or without graft or decompression; including medial to geniculate ganglion

Service Code
69745 (CPT) Suture facial nerve, intratemporal, with or without graft or decompression; including medial to geniculate ganglion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Implantable Bone Conduction Hearing Aids (BAHA)

Service Code
69799 (CPT) Unlisted procedure, middle ear
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

A bone-anchored hearing aid (BAHA) is a surgically implanted osseointegrated prosthetic device that provides bone conduction hearing for recipients with moderate to severe, bilateral conductive or mixed hearing loss who cannot wear a conventional air-conduction hearing aid or cannot reasonably or satisfactorily undergo ossicular replacement surgery. A BAHA device includes the implantation of a titanium abutment to which an external speech processor is attached.

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 this policy

Limits

Implantable bone conduction hearing aid devices must be FDA approved for the population being considered.

Exclusions

The BAHA is not covered when:

  • a. the beneficiary has a disease state that may jeopardize osseointegration;
  • b. the beneficiary can gain sufficient benefit from conventional amplification; or
  • c. the beneficiary’s audiometric criteria are outside the range of specifications

Age Group Details

Coverage is limited to beneficiaries 5 through 20 years of age for the implantable device service. Medically necessary maintenance and upgrades of existing internal components for next-generation devices are covered only for beneficiaries ages 5 years and older.

Place of Service

Hospital inpatient, hospital outpatient, ambulatory surgical center. No numeric place of service codes are listed in the policy.

Additional Service Specifics

Implantable bone conduction hearing aid devices shall be FDA approved for the population being considered.

How to Submit

Please submit your request to Trillium Health Resources

Resources

Labyrinthotomy, with perfusion of vestibuloactive drug(s), transcanal

Service Code
69801 (CPT) Labyrinthotomy, with perfusion of vestibuloactive drug(s), transcanal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Endolymphatic sac operation; without shunt

Service Code
69805 (CPT) Endolymphatic sac operation; without shunt
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Endolymphatic sac operation; with shunt

Service Code
69806 (CPT) Endolymphatic sac operation; with shunt
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Labyrinthectomy; transcanal

Service Code
69905 (CPT) Labyrinthectomy; transcanal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Labyrinthectomy; with mastoidectomy

Service Code
69910 (CPT) Labyrinthectomy; with mastoidectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Vestibular nerve section, translabyrinthine approach

Service Code
69915 (CPT) Vestibular nerve section, translabyrinthine approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Cochlear and Auditory Brainstem Implants

Service Code
69930 (CPT) Cochlear device implantation, with or without mastoidectomy
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

A cochlear implant is an electronic medical device designed to restore some ability to perceive sounds and understand speech by individuals with severe to profound hearing loss. A cochlear implant bypasses damaged hair cells in the cochlea and stimulates the remaining nerve fibers directly through the application of electrical current. Cochlear implants have external parts and internal (surgically implanted) parts that work together to allow the user to perceive sound.

An auditory brainstem implant (ABI) is a modification of the cochlear implant in which the stimulating electrode is placed directly into the brain.

After surgery, these two devices require activation, fitting of essential external components, programming, and rehabilitation for proper function and benefit.

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 this policy.

Limits

Postoperative activation, evaluation, and programming are covered as separate procedures only for beneficiaries ages 12 years through 20 years. Contralateral cochlear implant is considered only after successful placement of the original implant and on a case-by-case basis with documentation of medical necessity.

Simultaneous bilateral cochlear implants are covered only in the limited circumstances stated in policy.

Postoperative activation, evaluation, and programming are covered after the postoperative period for beneficiaries ages 12 months and older.

Exclusions

Aural rehabilitation for physicians is billed under Clinical Coverage Policy 10A, Outpatient Specialized Therapies.Billing unit limit: procedure codes in Section C are billed with 1 unit, except CPT 92640, which is billed as 1 unit = 1 hour.

Age Group Details

Auditory Brainstem Implants- 12 through 20 years of age, Cochlear Implants/Aural Rehabilitation/Contralateral Cochlear Implant-12 months of age and older,

Place of Service

Inpatient, Outpatient.

Additional Service Specifics

Simultaneous bilateral cochlear implants are billed with 69930 and modifier 50.

How to Submit

Please submit your request to Trillium Health Resources

Resources

Cochlear and Auditory Brainstem Implants

Service Code
69949 (CPT) Unlisted procedure, inner ear
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

A cochlear implant is an electronic medical device designed to restore some ability to perceive sounds and understand speech by individuals with severe to profound hearing loss. A cochlear implant bypasses damaged hair cells in the cochlea and stimulates the remaining nerve fibers directly through the application of electrical current. Cochlear implants have external parts and internal (surgically implanted) parts that work together to allow the user to perceive sound.

An auditory brainstem implant (ABI) is a modification of the cochlear implant in which the stimulating electrode is placed directly into the brain.

After surgery, these two devices require activation, fitting of essential external components, programming, and rehabilitation for proper function and benefit.

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 this policy.

Limits

Postoperative activation, evaluation, and programming are covered as separate procedures only for beneficiaries ages 12 years through 20 years. Contralateral cochlear implant is considered only after successful placement of the original implant and on a case-by-case basis with documentation of medical necessity.

Simultaneous bilateral cochlear implants are covered only in the limited circumstances stated in policy.

Postoperative activation, evaluation, and programming are covered after the postoperative period for beneficiaries ages 12 months and older.

Exclusions

Aural rehabilitation for physicians is billed under Clinical Coverage Policy 10A, Outpatient Specialized Therapies.Billing unit limit: procedure codes in Section C are billed with 1 unit, except CPT 92640, which is billed as 1 unit = 1 hour.

Age Group Details

Auditory Brainstem Implants- 12 through 20 years of age, Cochlear Implants/Aural Rehabilitation/Contralateral Cochlear Implant-12 months of age and older,

Place of Service

Inpatient, Outpatient.

Additional Service Specifics

Simultaneous bilateral cochlear implants are billed with 69930 and modifier 50.

How to Submit

Please submit your request to Trillium Health Resources

Resources

Vestibular nerve section, transcranial approach

Service Code
69950 (CPT) Vestibular nerve section, transcranial approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Total facial nerve decompression and/or repair (may include graft)

Service Code
69955 (CPT) Total facial nerve decompression and/or repair (may include graft)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Decompression internal auditory canal

Service Code
69960 (CPT) Decompression internal auditory canal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal of tumor, temporal bone

Service Code
69970 (CPT) Removal of tumor, temporal bone
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted procedure, temporal bone, middle fossa approach

Service Code
69979 (CPT) Unlisted procedure, temporal bone, middle fossa 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

Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)

Service Code
69990 (CPT) Microsurgical techniques, requiring use of operating microscope (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

Myelography, posterior fossa, radiological supervision and interpretation

Service Code
70010 (CPT) Myelography, posterior fossa, radiological supervision and interpretation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Cisternography, positive contrast, radiological supervision and interpretation

Service Code
70015 (CPT) Cisternography, positive contrast, radiological supervision and interpretation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Radiologic examination, eye, for detection of foreign body

Service Code
70030 (CPT) Radiologic examination, eye, for detection of foreign body
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required