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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

Staggered spondaic word test

Service Code
92572 (CPT) Staggered spondaic word test
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Carolina Complete Health through Availity

Resources

Synthetic sentence identification test

Service Code
92576 (CPT) Synthetic sentence identification test
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Carolina Complete Health through Availity

Resources

Visual reinforcement audiometry (VRA)

Service Code
92579 (CPT) Visual reinforcement audiometry (VRA)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Conditioning play audiometry

Service Code
92582 (CPT) Conditioning play audiometry
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Select picture audiometry

Service Code
92583 (CPT) Select picture audiometry
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report

Service Code
92587 (CPT) Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report

Service Code
92588 (CPT) Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Hearing aid examination and selection; monaural

Service Code
92590 (CPT) Hearing aid examination and selection; monaural
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Hearing aid examination and selection; binaural

Service Code
92591 (CPT) Hearing aid examination and selection; binaural
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Hearing aid check; monaural

Service Code
92592 (CPT) Hearing aid check; monaural
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Hearing aid check; binaural

Service Code
92593 (CPT) Hearing aid check; binaural
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Electroacoustic evaluation for hearing aid; monaural

Service Code
92594 (CPT) Electroacoustic evaluation for hearing aid; monaural
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Electroacoustic evaluation for hearing aid; binaural

Service Code
92595 (CPT) Electroacoustic evaluation for hearing aid; binaural
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech

Service Code
92597 (CPT) Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech
Prior Authorization Required
No
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

N/A - No authorization is required

Cochlear and Auditory Brainstem Implants

Service Code
92601 (CPT) (not found on description sheet)
Prior Authorization Required
No
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

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

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.

Resources

Cochlear and Auditory Brainstem Implants

Service Code
92602 (CPT) (not found on description sheet)
Prior Authorization Required
No
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

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

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.

Resources

Cochlear and Auditory Brainstem Implants

Service Code
92603 (CPT) (not found on description sheet)
Prior Authorization Required
No
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

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

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.

Resources

Cochlear and Auditory Brainstem Implants

Service Code
92604 (CPT) (not found on description sheet)
Prior Authorization Required
No
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

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

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.

Resources

Therapeutic service(s) for the use of non-speech-generating device, including programming and modification

Service Code
92606 (CPT) Therapeutic service(s) for the use of non-speech-generating device, including programming and modification
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.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour

Service Code
92607 (CPT) Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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