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

Ankle-foot orthosis (AFO), plastic with ankle joint, custom fabricated

Service Code
L1970 (HCPCS) Ankle-foot orthosis (AFO), plastic with ankle joint, custom fabricated
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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated

Service Code
L2106 (HCPCS) Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated
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

Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture cast orthosis, custom fabricated

Service Code
L2108 (HCPCS) Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture cast orthosis, custom fabricated
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

Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment

Service Code
L2116 (HCPCS) Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment
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

Knee-ankle-foot orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment

Service Code
L2136 (HCPCS) Knee-ankle-foot orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment
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

Addition to lower extremity orthosis, ankle system, microprocessor-controlled feature plantar flexion and/or dorsiflexion, includes power source

Service Code
L2221 (HCPCS) Addition to lower extremity orthosis, ankle system, microprocessor-controlled feature plantar flexion and/or dorsiflexion, includes power source
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

Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for PTB, AFO orthoses)

Service Code
L2350 (HCPCS) Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for PTB, AFO orthoses)
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

Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model

Service Code
L2510 (HCPCS) Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient 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

Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model

Service Code
L2525 (HCPCS) Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient 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

Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted

Service Code
L2526 (HCPCS) Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, 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

Addition to lower extremity, thigh/weight bearing, lacer, nonmolded

Service Code
L2530 (HCPCS) Addition to lower extremity, thigh/weight bearing, lacer, nonmolded
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

Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model

Service Code
L2540 (HCPCS) Addition to lower extremity, thigh/weight bearing, lacer, molded to patient 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

Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each

Service Code
L3000 (HCPCS) Foot insert, removable, molded to patient model, UCB type, Berkeley shell, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot, insert, removable, molded to patient model, Spenco, each

Service Code
L3001 (HCPCS) Foot, insert, removable, molded to patient model, Spenco, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot insert, removable, molded to patient model, Plastazote or equal, each

Service Code
L3002 (HCPCS) Foot insert, removable, molded to patient model, Plastazote or equal, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot insert, removable, molded to patient model, silicone gel, each

Service Code
L3003 (HCPCS) Foot insert, removable, molded to patient model, silicone gel, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot insert, removable, molded to patient model, longitudinal arch support, each

Service Code
L3010 (HCPCS) Foot insert, removable, molded to patient model, longitudinal arch support, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each

Service Code
L3020 (HCPCS) Foot insert, removable, molded to patient model, longitudinal/metatarsal support, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot insert, removable, formed to patient foot, each

Service Code
L3030 (HCPCS) Foot insert, removable, formed to patient foot, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot, arch support, removable, premolded, longitudinal, each

Service Code
L3040 (HCPCS) Foot, arch support, removable, premolded, longitudinal, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.