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
12465 Results
Delay of flap or sectioning of flap (division and inset); at trunk
Service Code
15600 (CPT) Delay of flap or sectioning of flap (division and inset); at trunk
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs
Service Code
15610 (CPT) Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet
Service Code
15620 (CPT) Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips
Service Code
15630 (CPT) Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any location
Service Code
15650 (CPT) Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any location
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)
Service Code
15730 (CPT) Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap)
Service Code
15731 (CPT) Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)
Service Code
15733 (CPT) Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Muscle, myocutaneous, or fasciocutaneous flap; trunk
Service Code
15734 (CPT) Muscle, myocutaneous, or fasciocutaneous flap; trunk
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Muscle, myocutaneous, or fasciocutaneous flap; upper extremity
Service Code
15736 (CPT) Muscle, myocutaneous, or fasciocutaneous flap; upper extremity
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Muscle, myocutaneous, or fasciocutaneous flap; lower extremity
Service Code
15738 (CPT) Muscle, myocutaneous, or fasciocutaneous flap; lower extremity
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel
Service Code
15740 (CPT) Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Flap; neurovascular pedicle
Service Code
15750 (CPT) Flap; neurovascular pedicle
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Free muscle or myocutaneous flap with microvascular anastomosis
Service Code
15756 (CPT) Free muscle or myocutaneous flap with microvascular anastomosis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Free skin flap with microvascular anastomosis
Service Code
15757 (CPT) Free skin flap with microvascular anastomosis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Free fascial flap with microvascular anastomosis
Service Code
15758 (CPT) Free fascial flap with microvascular anastomosis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, donor area
Service Code
15760 (CPT) Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, donor area
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
Service Code
15769 (CPT) Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
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
Graft; derma-fat-fascia
Service Code
15770 (CPT) Graft; derma-fat-fascia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
Service Code
15771 (CPT) Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
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
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