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

Standing frame/table system, one position (e.g., upright, supine or prone stander), any size including pediatric, with or without wheels

Service Code
E0638 (HCPCS) Standing frame/table system, one position (e.g., upright, supine or prone stander), any size including pediatric, with or without wheels
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

Standing frame/table system, multi-position (e.g., 3-way stander), any size including pediatric, with or without wheels

Service Code
E0641 (HCPCS) Standing frame/table system, multi-position (e.g., 3-way stander), any size including pediatric, with or without wheels
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

Standing frame/table system, mobile (dynamic stander), any size including pediatric

Service Code
E0642 (HCPCS) Standing frame/table system, mobile (dynamic stander), any size including pediatric
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

Pneumatic compressor, nonsegmental home model

Service Code
E0650 (HCPCS) Pneumatic compressor, nonsegmental home model
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

Pneumatic compressor, segmental home model without calibrated gradient pressure

Service Code
E0651 (HCPCS) Pneumatic compressor, segmental home model without calibrated gradient pressure
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

Pneumatic compressor, segmental home model with calibrated gradient pressure

Service Code
E0652 (HCPCS) Pneumatic compressor, segmental home model with calibrated gradient pressure
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

Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm

Service Code
E0655 (HCPCS) Nonsegmental pneumatic appliance for use with pneumatic compressor, half 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.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg

Service Code
E0660 (HCPCS) Nonsegmental pneumatic appliance for use with pneumatic compressor, full 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.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm

Service Code
E0665 (HCPCS) Nonsegmental pneumatic appliance for use with pneumatic compressor, full 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.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg

Service Code
E0666 (HCPCS) Nonsegmental pneumatic appliance for use with pneumatic compressor, half 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.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Segmental pneumatic appliance for use with pneumatic compressor, full leg

Service Code
E0667 (HCPCS) Segmental pneumatic appliance for use with pneumatic compressor, full 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.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Segmental pneumatic appliance for use with pneumatic compressor, full arm

Service Code
E0668 (HCPCS) Segmental pneumatic appliance for use with pneumatic compressor, full 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.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Segmental pneumatic appliance for use with pneumatic compressor, half leg

Service Code
E0669 (HCPCS) Segmental pneumatic appliance for use with pneumatic compressor, half 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.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Segmental pneumatic appliance for use with pneumatic compressor, integrated, two full legs and trunk

Service Code
E0670 (HCPCS) Segmental pneumatic appliance for use with pneumatic compressor, integrated, two full legs and trunk
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

Segmental gradient pressure pneumatic appliance, full leg

Service Code
E0671 (HCPCS) Segmental gradient pressure pneumatic appliance, full 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.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Segmental gradient pressure pneumatic appliance, full arm

Service Code
E0672 (HCPCS) Segmental gradient pressure pneumatic appliance, full 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.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Segmental gradient pressure pneumatic appliance, half leg

Service Code
E0673 (HCPCS) Segmental gradient pressure pneumatic appliance, half 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.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Nonpneumatic, nonsequential, peristaltic wave compression pump

Service Code
E0683 (HCPCS) Nonpneumatic, nonsequential, peristaltic wave compression pump
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

Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 sq ft or less

Service Code
E0691 (HCPCS) Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 sq ft or less
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

Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 ft panel

Service Code
E0692 (HCPCS) Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 ft panel
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