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

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Blepharoplasty and Blepharoptosis Eyelid Repair

Service Code
15823 (CPT) Blepharoplasty, upper eyelid; with excessive skin weighting down lid
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

Rhytidectomy; forehead

Service Code
15824 (CPT) Rhytidectomy; forehead
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

Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)

Service Code
15825 (CPT) Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)
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

Rhytidectomy; glabellar frown lines

Service Code
15826 (CPT) Rhytidectomy; glabellar frown lines
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

Rhytidectomy; cheek, chin, and neck

Service Code
15828 (CPT) Rhytidectomy; cheek, chin, and neck
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

Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap

Service Code
15829 (CPT) Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap
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

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

Service Code
15830 (CPT) Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
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

Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh

Service Code
15832 (CPT) Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
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

Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg

Service Code
15833 (CPT) Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
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

Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip

Service Code
15834 (CPT) Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
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

Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock

Service Code
15835 (CPT) Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock
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

Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm

Service Code
15836 (CPT) Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
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

Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand

Service Code
15837 (CPT) Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand
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

Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad

Service Code
15838 (CPT) Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad
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

Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area

Service Code
15839 (CPT) Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area
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 for facial nerve paralysis; free fascia graft (including obtaining fascia)

Service Code
15840 (CPT) Graft for facial nerve paralysis; free fascia graft (including obtaining fascia)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Graft for facial nerve paralysis; free muscle graft (including obtaining graft)

Service Code
15841 (CPT) Graft for facial nerve paralysis; free muscle graft (including obtaining graft)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Graft for facial nerve paralysis; free muscle flap by microsurgical technique

Service Code
15842 (CPT) Graft for facial nerve paralysis; free muscle flap by microsurgical technique
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Graft for facial nerve paralysis; regional muscle transfer

Service Code
15845 (CPT) Graft for facial nerve paralysis; regional muscle transfer
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)

Service Code
15847 (CPT) Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (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