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12437 Results

Fecal Microbiota Transplantation

Service Code
G0455 (HCPCS) Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Clostridium difficile is a disease-causing bacterium that can infect the large bowel and cause colitis.

Fecal microbiota transplantation (FMT) is the introduction of saline-diluted fecal matter (e.g., fecal suspension) derived from a healthy human donor into the gastrointestinal (GI) tract of an individual diagnosed with recurrent clostridium difficile infection (CDI), who has failed multiple attempts at conventional antibiotic therapy.

Clostridium difficile recurrence is defined by complete abatement of CDI symptoms while on appropriate therapy, followed by subsequent reappearance of diarrhea and other symptoms after treatment has been stopped. Recurrence must be distinguished from persistent diarrhea without resolution during initial therapy, which prompts an evaluation for other causes.

Recurrent clostridium difficile is associated with a decrease in fecal microbial diversity deficient in bacteroides and firmicutes, both of which generally dominate within the gut. Transplantation of stool from a healthy human donor to an individual with recurrent clostridium difficile restores the microbial deficiency and breaks the cycle of recurrence.

Fecal microbiota transplantation involves the restoration of the colonic flora by introducing healthy bacterial flora through infusion of stool by either retention enema, nasogastric tube, nasoduodenal tube, nasojejunal tube, colonoscope, an upper tract endoscope, or a combination of upper and lower approaches obtained from a healthy human donor.

Commonly, gastroenterologists recommend that fecal donors be healthy family members (i.e., parents, siblings, adult children of older beneficiaries) or spouses or significant partners who have common genetic and environmental factors.

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.

Exclusions

Medicaid shall not cover Fecal Microbiota Transplantation in the following situations:

  • a. when a beneficiary is under 21 years of age;
  • b. when an attempt to treat the recurrent CDI with antibiotic(s) was not tried

and was not successful, before performing fecal microbiota transplantation;

  • c. for inflammatory bowel disease;
  • d. for ulcerative colitis;
  • e. for Crohn’s disease;
  • f. for irritable bowel disease; or
  • g. for refractory constipation.

Note: In the absence of an alternative diagnosis, the beneficiary shall be considered to have a refractory illness.

Place of Service

Clinic, Outpatient hospital, Inpatient hospital

How to Submit

Please submit your request to Trillium Health Resources

Resources

G0463 25 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMEN

Service Code
G0463 (HCPCS) G0463 25 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMEN
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

Collection of venous blood by venipuncture or urine sample by catheterization from an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health agency (HHA)

Service Code
G0471 (HCPCS) Collection of venous blood by venipuncture or urine sample by catheterization from an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health agency (HHA)
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

Hepatitis C antibody screening for individual at high risk and other covered indication(s)

Service Code
G0472 (HCPCS) Hepatitis C antibody screening for individual at high risk and other covered indication(s)
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

HIV antigen/antibody, combination assay, screening

Service Code
G0475 (HCPCS) HIV antigen/antibody, combination assay, screening
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

Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus HPV), high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test

Service Code
G0476 (HCPCS) Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus HPV), high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test
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

G0477 DRUG TEST(S), PRESUMPTIVE,ANY NUMBER OF DRUG CLASSES;ANY NUMBER OF DEVICES OR PROCEDURES,(E.G.,IMMUNOASSAY) CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (E.G.,DIPSTICKS,CUPS,CARDS,CARTRIDGES),INCLUDES SAMPLE VALIDATION WHEN PERFORME

Service Code
G0477 (HCPCS) G0477 DRUG TEST(S), PRESUMPTIVE,ANY NUMBER OF DRUG CLASSES;ANY NUMBER OF DEVICES OR PROCEDURES,(E.G.,IMMUNOASSAY) CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (E.G.,DIPSTICKS,CUPS,CARDS,CARTRIDGES),INCLUDES SAMPLE VALIDATION WHEN PERFORME
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

G0478 Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when p

Service Code
G0478 (HCPCS) G0478 Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when p
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

G0479 59 DRUG TEST(S),PRESUMPTIVE,ANY NUMBER OF DRUG CLASSES;ANY NUMBER OF DEVICES OR PROCEDURES BY INSTRUMENTED CHEMISTRY ANALYZERS UTILIZING IMMUNOASSAY,ENZYME ASSAY,TOF,MALDI,LDTD,DESI,DART,GHPC,GC MASWS SPECTROMETRY),

Service Code
G0479 (HCPCS) G0479 59 DRUG TEST(S),PRESUMPTIVE,ANY NUMBER OF DRUG CLASSES;ANY NUMBER OF DEVICES OR PROCEDURES BY INSTRUMENTED CHEMISTRY ANALYZERS UTILIZING IMMUNOASSAY,ENZYME ASSAY,TOF,MALDI,LDTD,DESI,DART,GHPC,GC MASWS SPECTROMETRY),
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

G0480 59 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tande

Service Code
G0480 (HCPCS) G0480 59 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tande
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

G0481 DRUG TEST(S), DEFINITIVE, UTILIZING DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS;

Service Code
G0481 (HCPCS) G0481 DRUG TEST(S), DEFINITIVE, UTILIZING DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS;
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

G0482 DRUG TEST DEF 15-21 CLASSES

Service Code
G0482 (HCPCS) G0482 DRUG TEST DEF 15-21 CLASSES
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

G0483-DRUG TEST DEF 22+ CLASSES

Service Code
G0483 (HCPCS) G0483-DRUG TEST DEF 22+ CLASSES
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

Dialysis procedure at a Medicare certified ESRD facility for acute kidney injury without ESRD

Service Code
G0491 (HCPCS) Dialysis procedure at a Medicare certified ESRD facility for acute kidney injury without ESRD
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

Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible m

Service Code
G0493 (HCPCS) Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible m
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

Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for p

Service Code
G0494 (HCPCS) Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for p
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

Skilled services of a registered nurse (RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes

Service Code
G0495 (HCPCS) Skilled services of a registered nurse (RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes
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

Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes

Service Code
G0496 (HCPCS) Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes
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

Hepatitis B screening in nonpregnant, high-risk individual includes hepatitis B surface antigen (HBSAG), antibodies to HBSAG (anti-HBS) and antibodies to hepatitis B core antigen (anti-HBC), and is followed by a neutralizing confirmatory test, when perfor

Service Code
G0499 (HCPCS) Hepatitis B screening in nonpregnant, high-risk individual includes hepatitis B surface antigen (HBSAG), antibodies to HBSAG (anti-HBS) and antibodies to hepatitis B core antigen (anti-HBC), and is followed by a neutralizing confirmatory test, when perfor
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

Rural health clinic or federally qualified health center (RHC/FQHC) only, psychiatric collaborative care model (psychiatric COCM), 60 minutes or more of clinical staff time for psychiatric COCM services directed by an RHC or FQHC practitioner (physician,

Service Code
G0512 (HCPCS) Rural health clinic or federally qualified health center (RHC/FQHC) only, psychiatric collaborative care model (psychiatric COCM), 60 minutes or more of clinical staff time for psychiatric COCM services directed by an RHC or FQHC practitioner (physician,
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