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
12465 Results

Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure)

Service Code
15772 (CPT) Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure)
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

Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate

Service Code
15773 (CPT) Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 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

Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure)

Service Code
15774 (CPT) Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure)
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

Punch graft for hair transplant; 1 to 15 punch grafts

Service Code
15775 (CPT) Punch graft for hair transplant; 1 to 15 punch grafts
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

Punch graft for hair transplant; more than 15 punch grafts

Service Code
15776 (CPT) Punch graft for hair transplant; more than 15 punch grafts
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

Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure)

Service Code
15777 (CPT) Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (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

Implantation of absorbable mesh or other prosthesis for delayed closure of defect(s) (ie, external genitalia, perineum, abdominal wall) due to soft tissue infection or trauma

Service Code
15778 (CPT) Implantation of absorbable mesh or other prosthesis for delayed closure of defect(s) (ie, external genitalia, perineum, abdominal wall) due to soft tissue infection or trauma
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)

Service Code
15780 (CPT) Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)
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

Dermabrasion; segmental, face

Service Code
15781 (CPT) Dermabrasion; segmental, face
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

Dermabrasion; regional, other than face

Service Code
15782 (CPT) Dermabrasion; regional, other than face
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

Dermabrasion; superficial, any site (eg, tattoo removal)

Service Code
15783 (CPT) Dermabrasion; superficial, any site (eg, tattoo removal)
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

Abrasion; single lesion (eg, keratosis, scar)

Service Code
15786 (CPT) Abrasion; single lesion (eg, keratosis, scar)
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

Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure)

Service Code
15787 (CPT) Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure)
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

Chemical peel, facial; epidermal

Service Code
15788 (CPT) Chemical peel, facial; epidermal
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

Chemical peel, facial; dermal

Service Code
15789 (CPT) Chemical peel, facial; dermal
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

Chemical peel, nonfacial; epidermal

Service Code
15792 (CPT) Chemical peel, nonfacial; epidermal
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

Chemical peel, nonfacial; dermal

Service Code
15793 (CPT) Chemical peel, nonfacial; dermal
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

Blepharoplasty and Blepharoptosis Eyelid Repair

Service Code
15820 (CPT) Blepharoplasty, lower eyelid;
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Blepharoplasty and blepharoptosis eyelid repair are reconstructive plastic surgery procedures of the eyelids. Surgery of the upper eyelids is reconstructive when it provides functional vision or visual field benefits or improves the functioning of a malformed or degenerated body member. The goal of reconstructive surgery is to restore function to the eye structure.

Authorization Guidelines

The provider(s) shall submit:

  • a. the prior approval request; and
  • b. all health records and any other records that support the beneficiary has met

the specific criteria in Subsection 3.2 of this policy. Prior approval for home health services is required for the following:

  • a. Miscellaneous Therapeutic Items and Supplies: Supply Procedure Code.

Refer to Attachment A: Code(s) for prior approval and limit specifications.

Submit prior approval requests via the secure NC Tracks Provider portal. PA requests cannot be submitted by paper via fax, email, postal service, or by phone.b. Medical supplies, appliances, and equipment not listed on the fee schedule may be considered for coverage, if submitted for prior authorization (PA) review of medical necessity. For a beneficiary aged 21 or older, please follow the procedure detailed in Attachment B and posted on the Home Health Services webpage at https://medicaid.ncdhhs.gov/.

Exclusions

Medicaid shall not cover blepharoplasty and blepharoptosis eyelid repair performed solely for cosmetic reasons to enhance aesthetic appearance.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Blepharoplasty and Blepharoptosis Eyelid Repair

Service Code
15821 (CPT) Blepharoplasty, lower eyelid; with extensive herniated fat pad
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Blepharoplasty and blepharoptosis eyelid repair are reconstructive plastic surgery procedures of the eyelids. Surgery of the upper eyelids is reconstructive when it provides functional vision or visual field benefits or improves the functioning of a malformed or degenerated body member. The goal of reconstructive surgery is to restore function to the eye structure.

Authorization Guidelines

The provider(s) shall submit:

  • a. the prior approval request; and
  • b. all health records and any other records that support the beneficiary has met

the specific criteria in Subsection 3.2 of this policy. Prior approval for home health services is required for the following:

  • a. Miscellaneous Therapeutic Items and Supplies: Supply Procedure Code.

Refer to Attachment A: Code(s) for prior approval and limit specifications.

Submit prior approval requests via the secure NC Tracks Provider portal. PA requests cannot be submitted by paper via fax, email, postal service, or by phone.b. Medical supplies, appliances, and equipment not listed on the fee schedule may be considered for coverage, if submitted for prior authorization (PA) review of medical necessity. For a beneficiary aged 21 or older, please follow the procedure detailed in Attachment B and posted on the Home Health Services webpage at https://medicaid.ncdhhs.gov/.

Exclusions

Medicaid shall not cover blepharoplasty and blepharoptosis eyelid repair performed solely for cosmetic reasons to enhance aesthetic appearance.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Blepharoplasty and Blepharoptosis Eyelid Repair

Service Code
15822 (CPT) Blepharoplasty, upper eyelid;
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Blepharoplasty and blepharoptosis eyelid repair are reconstructive plastic surgery procedures of the eyelids. Surgery of the upper eyelids is reconstructive when it provides functional vision or visual field benefits or improves the functioning of a malformed or degenerated body member. The goal of reconstructive surgery is to restore function to the eye structure.

Authorization Guidelines

The provider(s) shall submit:

  • a. the prior approval request; and
  • b. all health records and any other records that support the beneficiary has met

the specific criteria in Subsection 3.2 of this policy. Prior approval for home health services is required for the following:

  • a. Miscellaneous Therapeutic Items and Supplies: Supply Procedure Code.

Refer to Attachment A: Code(s) for prior approval and limit specifications.

Submit prior approval requests via the secure NC Tracks Provider portal. PA requests cannot be submitted by paper via fax, email, postal service, or by phone.b. Medical supplies, appliances, and equipment not listed on the fee schedule may be considered for coverage, if submitted for prior authorization (PA) review of medical necessity. For a beneficiary aged 21 or older, please follow the procedure detailed in Attachment B and posted on the Home Health Services webpage at https://medicaid.ncdhhs.gov/.

Exclusions

Medicaid shall not cover blepharoplasty and blepharoptosis eyelid repair performed solely for cosmetic reasons to enhance aesthetic appearance.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources