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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Gauze, impregnated, water or normal saline, sterile, pad size 16 sq in or less, without adhesive border, each dressing

Service Code
A6228 (HCPCS) Gauze, impregnated, water or normal saline, sterile, pad size 16 sq in or less, without adhesive border, each dressing
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Transparent film, sterile, 16 sq in or less, each dressing

Service Code
A6257 (HCPCS) Transparent film, sterile, 16 sq in or less, each dressing
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Transparent film, sterile, more than 16 sq in but less than or equal to 48 sq in, each dressing

Service Code
A6258 (HCPCS) Transparent film, sterile, more than 16 sq in but less than or equal to 48 sq in, each dressing
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Transparent film, sterile, more than 48 sq in, each dressing

Service Code
A6259 (HCPCS) Transparent film, sterile, more than 48 sq in, each dressing
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Gauze, nonimpregnated, sterile, pad size 16 sq in or less, without adhesive border, each dressing

Service Code
A6402 (HCPCS) Gauze, nonimpregnated, sterile, pad size 16 sq in or less, without adhesive border, each dressing
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Gradient compression wrap with adjustable straps, full leg, each, custom

Service Code
A6515 (HCPCS) Gradient compression wrap with adjustable straps, full leg, each, custom
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

Gradient compression wrap with adjustable straps, foot, each, custom

Service Code
A6516 (HCPCS) Gradient compression wrap with adjustable straps, foot, each, custom
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

Gradient compression wrap with adjustable straps, below knee, each, custom

Service Code
A6517 (HCPCS) Gradient compression wrap with adjustable straps, below knee, each, custom
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

Gradient compression wrap with adjustable straps, arm, each, custom

Service Code
A6518 (HCPCS) Gradient compression wrap with adjustable straps, arm, each, custom
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

Gradient compression garment, not otherwise specified, for nighttime use, each

Service Code
A6519 (HCPCS) Gradient compression garment, not otherwise specified, for nighttime use, each
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

Accessory to custom gradient compression garment, silicone band, any size

Service Code
A6548 (HCPCS) Accessory to custom gradient compression garment, silicone band, any size
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Gradient compression stocking/sleeve, not otherwise specified

Service Code
A6549 (HCPCS) Gradient compression stocking/sleeve, not otherwise specified
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

Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories

Service Code
A6550 (HCPCS) Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

External urinary catheters; disposable, with wicking material, for use with suction pump, per month

Service Code
A6590 (HCPCS) External urinary catheters; disposable, with wicking material, for use with suction pump, per month
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

External urinary catheter; non-disposable, for use with suction pump, per month

Service Code
A6591 (HCPCS) External urinary catheter; non-disposable, for use with suction pump, per month
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

Gradient compression wrap with adjustable straps, above knee, each, custom

Service Code
A6611 (HCPCS) Gradient compression wrap with adjustable straps, above knee, each, custom
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

Canister, disposable, used with suction pump, each

Service Code
A7000 (HCPCS) Canister, disposable, used with suction pump, each
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Canister, nondisposable, used with suction pump, each

Service Code
A7001 (HCPCS) Canister, nondisposable, used with suction pump, each
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Tubing, used with suction pump, each

Service Code
A7002 (HCPCS) Tubing, used with suction pump, each
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Large volume nebulizer, disposable, unfilled, used with aerosol compressor

Service Code
A7007 (HCPCS) Large volume nebulizer, disposable, unfilled, used with aerosol compressor
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity