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
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation;
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
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, ven
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
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization
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
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, ven
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
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ven
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
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ven
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
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) fo
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
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) fo
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
Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure)
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
Pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after and repeat pharmacologic agent administration, w
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
Physiologic exercise study (eg, bicycle or arm ergometry) including assessing hemodynamic measurements before and after (List separately in addition to code for primary procedure)
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
Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective left ventricular or left atrial angiography (List separately in addition to code for primary procedure)
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
Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective right ventricular or right atrial angiography (List separately in addition to code for primary procedure)
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
Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography (List separately in addition to code for primary procedure)
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
Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for pulmonary angiography (List separately in addition to code for primary procedure)
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
SET-UP CARDIOVERT-DEFIBRILL
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 the Turning Point site for specific requirements
How to Submit
Please submit your request to Turning Point
Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood samp
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
Phase II Outpatient Cardiac Rehabilitation Programs
Phase II outpatient cardiac rehabilitation is a comprehensive program of medical evaluation designed to recondition the cardiovascular system and restore beneficiaries with cardiovascular heart disease to active and productive lives. A cardiac rehabilitation program includes prescribed exercise; cardiac risk factor modification; education; and counseling, which includes diet instruction and disease management. It is used to assist beneficiaries 8 years of age and older in dealing with active heart disease and must be performed in a participating facility that has current certification under the Division of Health Service Regulation in accordance with 10A NCAC 14F.1100 through 14F.2106.
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
One unit = 1 session.
Limits
Covered program must be Phase II outpatient cardiac rehabilitation and must be performed in a participating facility with current Division of Health Service Regulation certification.
The program must be initiated within 6 months of a qualifying cardiac condition.
Length of Stay
High-risk patients: up to 36 sessions, three times per week for 12 weeks.
Intermediate-risk patients: up to 24 sessions, three times per week for 8 weeks.
Low-risk patients: up to 6 one-hour sessions, three times per week for 2 weeks.
Exercise therapy duration is up to 60 minutes as tolerated, including at least 5 minutes each for warm-up and cool-down.
Exercise therapy frequency is a minimum of 3 days per week.
Exclusions
A Phase II outpatient cardiac rehabilitation program is not covered for high-risk beneficiaries if continuous ECG monitoring is not performed. Contraindications to an outpatient cardiac rehabilitation program include marked progressive worsening of exercise tolerance suggesting an acute pathologic process, worsening dyspnea during exercise over the previous 3 to 5 days, acute systemic illness or fever, acute pericarditis, moderate to severe aortic stenosis, new onset atrial fibrillation, recent embolism, acute thrombophlebitis, unstable ischemia, uncontrolled arrhythmias, decompensated congestive heart failure, uncontrolled diabetes, and MI within 2 weeks.
Diagnosis Requirements
The program is covered when initiated within 6 months of one of the following qualifying conditions: acute myocardial infarction; coronary artery bypass grafting; percutaneous transluminal coronary angioplasty or coronary artery stenting; heart or heart-lung transplant; heart valve repair or replacement; stable angina pectoris; surgery to palliate a congenital heart defect; repaired or unrepaired congenital heart disease with functional limitations; or cardiomyopathy with stable ventricular function.
Age Group Details
Service is limited to beneficiaries 8 years of age and older.
Place of Service
Hospital outpatient clinics, Physicians' offices, and Medical diagnostic clinics.
Additional Service Specifics
The beneficiary also must meet one risk category. High-risk criteria include any of: exercise capacity less than or equal to 5 METs; marked exercise-induced ischemia with anginal pain, at least 2 mm ST depression by ECG, or shortness of breath related to cardiac ischemia; severely depressed left ventricular function such as ejection fraction less than or equal to 30%; resting complex ventricular arrhythmia; ventricular arrhythmia appearing or increasing with exercise or in recovery; systolic blood pressure decrease of 15 to 20 mmHg or more with exercise; MI within the last 6 months complicated by serious ventricular arrhythmia; recent sudden cardiac arrest; or shock or CHF during an MI occurring less than 3 months previously. Intermediate-risk criteria include any of: exercise capacity 6 to 9 METs; ischemic ECG response to exercise of less than 2 mm ST depression; uncomplicated MI, CABG, or angioplasty with post-cardiac event maximal functional capacity of 8 METs or less on ECG exercise test; congenital heart disease with palliated biventricular physiology; or congenital heart disease assessed as intermediate risk by the beneficiary's cardiologist. Low-risk criteria include any of: exercise capacity greater than 9 METs; successfully repaired biventricular congenital heart disease; or congenital heart disease assessed as low risk by the beneficiary's cardiologist. Risk stratification is generally documented as high, intermediate, or low risk and includes degree of exercise limitation on a treadmill ECG stress test performed within 3 weeks of program initiation. Measurement is determined using METs achieved on a qualifying treadmill or cycle ergometer test performed before participation. For beneficiaries ages 8 to 18 with congenital heart defects, risk stratification may also include baseline oxygen saturation, palliated physiology, the specific defect, associated arrhythmia history, or a cardiologist statement addressing hemodynamic status, defect nature, and expected exercise response.
Other Information
Hospital outpatient clinics bill for services using RC 943.
How to Submit
N/A - No authorization is required
Resources
Phase II Outpatient Cardiac Rehabilitation Programs
Phase II outpatient cardiac rehabilitation is a comprehensive program of medical evaluation designed to recondition the cardiovascular system and restore beneficiaries with cardiovascular heart disease to active and productive lives. A cardiac rehabilitation program includes prescribed exercise; cardiac risk factor modification; education; and counseling, which includes diet instruction and disease management. It is used to assist beneficiaries 8 years of age and older in dealing with active heart disease and must be performed in a participating facility that has current certification under the Division of Health Service Regulation in accordance with 10A NCAC 14F.1100 through 14F.2106.
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
One unit = 1 session.
Limits
Covered program must be Phase II outpatient cardiac rehabilitation and must be performed in a participating facility with current Division of Health Service Regulation certification.
The program must be initiated within 6 months of a qualifying cardiac condition.
Length of Stay
High-risk patients: up to 36 sessions, three times per week for 12 weeks.
Intermediate-risk patients: up to 24 sessions, three times per week for 8 weeks.
Low-risk patients: up to 6 one-hour sessions, three times per week for 2 weeks.
Exercise therapy duration is up to 60 minutes as tolerated, including at least 5 minutes each for warm-up and cool-down.
Exercise therapy frequency is a minimum of 3 days per week.
Exclusions
A Phase II outpatient cardiac rehabilitation program is not covered for high-risk beneficiaries if continuous ECG monitoring is not performed. Contraindications to an outpatient cardiac rehabilitation program include marked progressive worsening of exercise tolerance suggesting an acute pathologic process, worsening dyspnea during exercise over the previous 3 to 5 days, acute systemic illness or fever, acute pericarditis, moderate to severe aortic stenosis, new onset atrial fibrillation, recent embolism, acute thrombophlebitis, unstable ischemia, uncontrolled arrhythmias, decompensated congestive heart failure, uncontrolled diabetes, and MI within 2 weeks.
Diagnosis Requirements
The program is covered when initiated within 6 months of one of the following qualifying conditions: acute myocardial infarction; coronary artery bypass grafting; percutaneous transluminal coronary angioplasty or coronary artery stenting; heart or heart-lung transplant; heart valve repair or replacement; stable angina pectoris; surgery to palliate a congenital heart defect; repaired or unrepaired congenital heart disease with functional limitations; or cardiomyopathy with stable ventricular function.
Age Group Details
Service is limited to beneficiaries 8 years of age and older.
Place of Service
Hospital outpatient clinics, Physicians' offices, and Medical diagnostic clinics.
Additional Service Specifics
The beneficiary also must meet one risk category. High-risk criteria include any of: exercise capacity less than or equal to 5 METs; marked exercise-induced ischemia with anginal pain, at least 2 mm ST depression by ECG, or shortness of breath related to cardiac ischemia; severely depressed left ventricular function such as ejection fraction less than or equal to 30%; resting complex ventricular arrhythmia; ventricular arrhythmia appearing or increasing with exercise or in recovery; systolic blood pressure decrease of 15 to 20 mmHg or more with exercise; MI within the last 6 months complicated by serious ventricular arrhythmia; recent sudden cardiac arrest; or shock or CHF during an MI occurring less than 3 months previously. Intermediate-risk criteria include any of: exercise capacity 6 to 9 METs; ischemic ECG response to exercise of less than 2 mm ST depression; uncomplicated MI, CABG, or angioplasty with post-cardiac event maximal functional capacity of 8 METs or less on ECG exercise test; congenital heart disease with palliated biventricular physiology; or congenital heart disease assessed as intermediate risk by the beneficiary's cardiologist. Low-risk criteria include any of: exercise capacity greater than 9 METs; successfully repaired biventricular congenital heart disease; or congenital heart disease assessed as low risk by the beneficiary's cardiologist. Risk stratification is generally documented as high, intermediate, or low risk and includes degree of exercise limitation on a treadmill ECG stress test performed within 3 weeks of program initiation. Measurement is determined using METs achieved on a qualifying treadmill or cycle ergometer test performed before participation. For beneficiaries ages 8 to 18 with congenital heart defects, risk stratification may also include baseline oxygen saturation, palliated physiology, the specific defect, associated arrhythmia history, or a cardiologist statement addressing hemodynamic status, defect nature, and expected exercise response.
Other Information
Hospital outpatient clinics bill for services using RC 943.
How to Submit
N/A - No authorization is required
Resources
Unlisted cardiovascular service or procedure
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
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.