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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12437 Results

Helmet, protective, hard, custom fabricated, includes all components and accessories

Service Code
A8003 (HCPCS) Helmet, protective, hard, custom fabricated, includes all components 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

Soft interface for helmet, replacement only

Service Code
A8004 (HCPCS) Soft interface for helmet, replacement only
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

Powered, cable driven grip assist glove, hand, finger, includes microprocessor, pressure sensors, all components and accessories, custom fitted

Service Code
A8005 (HCPCS) Powered, cable driven grip assist glove, hand, finger, includes microprocessor, pressure sensors, all components and accessories, custom fitted
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

Powered, cable driven grip assist glove, hand, finger, includes pressure sensors, glove replacement only

Service Code
A8006 (HCPCS) Powered, cable driven grip assist glove, hand, finger, includes pressure sensors, glove replacement only
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

Artificial saliva, 1 ml

Service Code
A9154 (HCPCS) Artificial saliva, 1 ml
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

Oral mucoadhesive, any type (liquid, gel, paste, etc.), per 1 ml

Service Code
A9156 (HCPCS) Oral mucoadhesive, any type (liquid, gel, paste, etc.), per 1 ml
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

Programmer for transient, orally ingested capsule

Service Code
A9268 (HCPCS) Programmer for transient, orally ingested capsule
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

Programmable, transient, orally ingested capsule, for use with external programmer, per month

Service Code
A9269 (HCPCS) Programmable, transient, orally ingested capsule, for use with external programmer, per month
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

A9270 NON-COVERED ITEM OR SERVICE;ITEM/SRVCE STATUTORILY EXCLUDED OR DOES NOT MEET DEFINITION OF ANY MEDICARE BNFT

Service Code
A9270 (HCPCS) A9270 NON-COVERED ITEM OR SERVICE;ITEM/SRVCE STATUTORILY EXCLUDED OR DOES NOT MEET DEFINITION OF ANY MEDICARE BNFT
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 ambulatory insulin delivery system, disposable, each, includes all supplies and accessories

Service Code
A9274 (HCPCS) External ambulatory insulin delivery system, disposable, each, 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

Home glucose disposable monitor, includes test strips

Service Code
A9275 (HCPCS) Home glucose disposable monitor, includes test strips
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

Spirometer, nonelectronic, includes all accessories

Service Code
A9284 (HCPCS) Spirometer, nonelectronic, includes all 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

Prescription digital cognitive and/or behavioral therapy, biofeedback, FDA cleared, per course of treatment

Service Code
A9294 (HCPCS) Prescription digital cognitive and/or behavioral therapy, biofeedback, FDA cleared, per course of treatment
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

Technetium Tc-99m sestamibi, diagnostic, per study dose

Service Code
A9500 (HCPCS) Technetium Tc-99m sestamibi, diagnostic, per study dose
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

Technetium Tc-99m tetrofosmin, diagnostic, per study dose

Service Code
A9502 (HCPCS) Technetium Tc-99m tetrofosmin, diagnostic, per study dose
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

Thallium Tl-201 thallous chloride, diagnostic, per mCi

Service Code
A9505 (HCPCS) Thallium Tl-201 thallous chloride, diagnostic, per mCi
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

Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 mCi

Service Code
A9552 (HCPCS) Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 mCi
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

Rubidium Rb-82, diagnostic, per study dose, up to 60 mCi

Service Code
A9555 (HCPCS) Rubidium Rb-82, diagnostic, per study dose, up to 60 mCi
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

A9579 GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOS, PER ML

Service Code
A9579 (HCPCS) A9579 GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOS, PER ML
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

Gallium Ga-68 PSMA-11, diagnostic, (UCSF), 1 mCi

Service Code
A9593 (HCPCS) Gallium Ga-68 PSMA-11, diagnostic, (UCSF), 1 mCi
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