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

Upper extremity addition, external frame, partial hand including fingers

Service Code
L6030 (HCPCS) Upper extremity addition, external frame, partial hand including fingers
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

Replacement socket/interface, partial hand including fingers, molded to patient model, for use with or without external power

Service Code
L6031 (HCPCS) Replacement socket/interface, partial hand including fingers, molded to patient model, for use with or without external power
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 upper extremity prosthesis, partial hand including fingers, ultralight material (titanium, carbon fiber or equal)

Service Code
L6032 (HCPCS) Addition to upper extremity prosthesis, partial hand including fingers, ultralight material (titanium, carbon fiber or equal)
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 upper extremity prosthesis, partial hand including fingers, acrylic material

Service Code
L6033 (HCPCS) Addition to upper extremity prosthesis, partial hand including fingers, acrylic material
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

Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, partial hand including fingers

Service Code
L6037 (HCPCS) Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, partial hand including fingers
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

Immediate postsurgical or early fitting, application of rigid dressing only

Service Code
L6388 (HCPCS) Immediate postsurgical or early fitting, application of rigid dressing 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

Upper extremity addition, spring assisted rotational wrist unit with latch release

Service Code
L6623 (HCPCS) Upper extremity addition, spring assisted rotational wrist unit with latch release
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

Upper extremity addition, suction socket

Service Code
L6686 (HCPCS) Upper extremity addition, suction socket
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

Upper extremity addition, frame type socket, shoulder disarticulation

Service Code
L6689 (HCPCS) Upper extremity addition, frame type socket, shoulder disarticulation
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

Upper extremity addition, locking elbow, forearm counterbalance

Service Code
L6693 (HCPCS) Upper extremity addition, locking elbow, forearm counterbalance
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 upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert

Service Code
L6698 (HCPCS) Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert
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

Upper extremity addition, external powered feature, myoelectronic control module, additional EMG inputs, pattern-recognition decoding intent movement

Service Code
L6700 (HCPCS) Upper extremity addition, external powered feature, myoelectronic control module, additional EMG inputs, pattern-recognition decoding intent movement
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

Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined

Service Code
L6707 (HCPCS) Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined
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

Terminal device, hand, mechanical, voluntary opening, any material, any size

Service Code
L6708 (HCPCS) Terminal device, hand, mechanical, voluntary opening, any material, 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

Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric

Service Code
L6711 (HCPCS) Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, 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

Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric

Service Code
L6712 (HCPCS) Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, 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

Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric

Service Code
L6713 (HCPCS) Terminal device, hand, mechanical, voluntary opening, any material, any size, 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

Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric

Service Code
L6714 (HCPCS) Terminal device, hand, mechanical, voluntary closing, any material, any size, 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

Terminal device, hook or hand, heavy-duty, mechanical, voluntary opening, any material, any size, lined or unlined

Service Code
L6721 (HCPCS) Terminal device, hook or hand, heavy-duty, mechanical, voluntary opening, any material, any size, lined or unlined
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

Terminal device, hook or hand, heavy-duty, mechanical, voluntary closing, any material, any size, lined or unlined

Service Code
L6722 (HCPCS) Terminal device, hook or hand, heavy-duty, mechanical, voluntary closing, any material, any size, lined or unlined
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