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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Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power

Service Code
L6883 (HCPCS) Replacement socket, below elbow/wrist disarticulation, 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

Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power

Service Code
L6884 (HCPCS) Replacement socket, above elbow/elbow disarticulation, 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

Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power

Service Code
L6885 (HCPCS) Replacement socket, shoulder disarticulation/interscapular thoracic, 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

Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining

Service Code
L6905 (HCPCS) Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining
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, shoulder disarticulation/interscapular thoracic, acrylic material

Service Code
L7405 (HCPCS) Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, 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

Addition to upper extremity, user adjustable, mechanical, residual limb volume management system

Service Code
L7406 (HCPCS) Addition to upper extremity, user adjustable, mechanical, residual limb volume management system
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 Band and Implantable Bone Conduction Clinical Coverage Policy No.: 13B Hearing Aids External Parts Replacement and Repair

Service Code
L7510 (HCPCS) Repair of prosthetic device, repair or replace minor parts
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

The NC Medicaid (Medicaid) program provides soft band bone conduction hearing aids (not implanted) and replacement or repair of external parts for both soft band and implantable bone conduction hearing aids, when there is medical necessity. Replacement and repair of components of soft band and implantable bone conduction hearing aids are necessary to maintain the device’s ability to analyze and code sound, therefore providing an awareness and identification of sounds and facilitating communication for individuals.

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.

Unit Value

  • 1. Purchased Equipment: The unit of service is 1 for each item provided.
  • 2. Service and Repair: The unit of service is 1 for each service or repair.

Exclusions

External parts replacement and repair are not covered when the request is for a sound processor, battery replacement, or repair as spare or back-up equipment for use in emergencies; when the request for a soft band bone conduction hearing aid is for unilateral sensorineural hearing loss (single sided deafness); when the component or service is for a resident of a nursing facility; or when the component or service is covered by another agency. Upgrades to existing, functioning, replaceable sound processors for aesthetic improvement are not medically necessary and are not covered.

Age Group Details

New Soft Band Bone Conduction Hearing Aid: covered when the beneficiary is a candidate for bone conduction hearing aid implant surgery and has not reached the age of 5 years or is under 21 years of age and is not an appropriate surgical candidate; External Parts Replacement and Repair for Soft Band and Implantable Bone Conduction Hearing Aids – Out of Warranty: The beneficiary is approved for and is currently wearing a soft band bone conduction hearing aid prior to turning 21 years of age or is 5 years of age or older and implanted

Place of Service

Beneficiary's home

Other Information

The provider must obtain prior approval from NC Medicaid through NCTracks and submit an electronic prior approval request with a copy of the otolaryngologist medical clearance for a soft band device or a copy of the prescribing physician's original prescription with surgery information for an implanted device, plus a letter of medical necessity from the treating audiologist. If the requested identical replacement sound processor is under warranty, prior approval is not required.

How to Submit

Please submit your request to Trillium Health Resources

Resources

Repair prosthetic device, labor component, per 15 minutes

Service Code
L7520 (HCPCS) Repair prosthetic device, labor component, per 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

Breast prosthesis, silicone or equal, without integral adhesive

Service Code
L8030 (HCPCS) Breast prosthesis, silicone or equal, without integral adhesive
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

No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.

How to Submit

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

Breast prosthesis, not otherwise specified

Service Code
L8039 (HCPCS) Breast prosthesis, not otherwise specified
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

No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.

How to Submit

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

Tracheostomy speaking valve

Service Code
L8501 (HCPCS) Tracheostomy speaking valve
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

Implantable breast prosthesis, silicone or equal

Service Code
L8600 (HCPCS) Implantable breast prosthesis, silicone 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

Conditional Requirements

No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.

How to Submit

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

Headset/headpiece for use with cochlear implant device, replacement

Service Code
L8615 (HCPCS) Headset/headpiece for use with cochlear implant device, replacement
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Replacement and repair of external components of a cochlear or auditory brainstem implant device that are necessary to maintain the device’s ability to analyze and code sound, therefore providing an awareness and identification of sounds and facilitating communication for individuals with severe to profound hearing loss.

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.

Unit Value

The unit of service is 1 for each item provided.

Limits

Once every 3 years

Exclusions

Cochlear and auditory brainstem implant external parts replacement and repair are also not covered when the component or service is for a resident of a nursing facility or is covered by another agency. Upgrades to existing, functioning, replaceable speech processors for aesthetic improvement are not medically necessary and will not be covered. No charge to Medicaid is allowed for replacement or repairs covered under warranty, pick-up or delivery of the item, or assembly of Medicaid reimbursed parts.

Diagnosis Requirements

The service is for replacement and repair of external cochlear or auditory brainstem implant components necessary to maintain the device's ability to analyze and code sound, thereby supporting awareness and identification of sounds and communication for individuals with severe to profound hearing loss.

Place of Service

Beneficiary's home.

How to Submit

Please submit your request to Trillium Health Resources

Resources

Microphone for use with cochlear implant device, replacement

Service Code
L8616 (HCPCS) Microphone for use with cochlear implant device, replacement
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Replacement and repair of external components of a cochlear or auditory brainstem implant device that are necessary to maintain the device’s ability to analyze and code sound, therefore providing an awareness and identification of sounds and facilitating communication for individuals with severe to profound hearing loss.

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.

Unit Value

The unit of service is 1 for each item provided.

Limits

Once annually

Exclusions

Cochlear and auditory brainstem implant external parts replacement and repair are also not covered when the component or service is for a resident of a nursing facility or is covered by another agency. Upgrades to existing, functioning, replaceable speech processors for aesthetic improvement are not medically necessary and will not be covered. No charge to Medicaid is allowed for replacement or repairs covered under warranty, pick-up or delivery of the item, or assembly of Medicaid reimbursed parts.

Diagnosis Requirements

The service is for replacement and repair of external cochlear or auditory brainstem implant components necessary to maintain the device's ability to analyze and code sound, thereby supporting awareness and identification of sounds and communication for individuals with severe to profound hearing loss.

Place of Service

Beneficiary's home.

How to Submit

Please submit your request to Trillium Health Resources

Resources

Transmitting coil for use with cochlear implant device, replacement

Service Code
L8617 (HCPCS) Transmitting coil for use with cochlear implant device, replacement
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

Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement

Service Code
L8618 (HCPCS) Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Replacement and repair of external components of a cochlear or auditory brainstem implant device that are necessary to maintain the device’s ability to analyze and code sound, therefore providing an awareness and identification of sounds and facilitating communication for individuals with severe to profound hearing loss.

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.

Unit Value

The unit of service is 1 for each item provided.

Limits

8 times each year

Exclusions

Cochlear and auditory brainstem implant external parts replacement and repair are also not covered when the component or service is for a resident of a nursing facility or is covered by another agency. Upgrades to existing, functioning, replaceable speech processors for aesthetic improvement are not medically necessary and will not be covered. No charge to Medicaid is allowed for replacement or repairs covered under warranty, pick-up or delivery of the item, or assembly of Medicaid reimbursed parts.

Diagnosis Requirements

The service is for replacement and repair of external cochlear or auditory brainstem implant components necessary to maintain the device's ability to analyze and code sound, thereby supporting awareness and identification of sounds and communication for individuals with severe to profound hearing loss.

Place of Service

Beneficiary's home.

How to Submit

Please submit your request to Trillium Health Resources

Resources

Cochlear implant, external speech processor and controller, integrated system, replacement

Service Code
L8619 (HCPCS) Cochlear implant, external speech processor and controller, integrated system, replacement
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

Soft Band and Implantable Bone Conduction Clinical Coverage Policy No.: 13B Hearing Aids External Parts Replacement and Repair

Service Code
L8621 (HCPCS) Zinc air battery for use with cochlear implant device and auditory osseointegrated sound processors, replacement, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

The NC Medicaid (Medicaid) program provides soft band bone conduction hearing aids (not implanted) and replacement or repair of external parts for both soft band and implantable bone conduction hearing aids, when there is medical necessity. Replacement and repair of components of soft band and implantable bone conduction hearing aids are necessary to maintain the device’s ability to analyze and code sound, therefore providing an awareness and identification of sounds and facilitating communication for individuals.

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.

Unit Value

  • 1. Purchased Equipment: The unit of service is 1 for each item provided.
  • 2. Service and Repair: The unit of service is 1 for each service or repair.

Exclusions

External parts replacement and repair are not covered when the request is for a sound processor, battery replacement, or repair as spare or back-up equipment for use in emergencies; when the request for a soft band bone conduction hearing aid is for unilateral sensorineural hearing loss (single sided deafness); when the component or service is for a resident of a nursing facility; or when the component or service is covered by another agency. Upgrades to existing, functioning, replaceable sound processors for aesthetic improvement are not medically necessary and are not covered.

Age Group Details

New Soft Band Bone Conduction Hearing Aid: covered when the beneficiary is a candidate for bone conduction hearing aid implant surgery and has not reached the age of 5 years or is under 21 years of age and is not an appropriate surgical candidate; External Parts Replacement and Repair for Soft Band and Implantable Bone Conduction Hearing Aids – Out of Warranty: The beneficiary is approved for and is currently wearing a soft band bone conduction hearing aid prior to turning 21 years of age or is 5 years of age or older and implanted

Place of Service

Beneficiary's home

Other Information

The provider must obtain prior approval from NC Medicaid through NCTracks and submit an electronic prior approval request with a copy of the otolaryngologist medical clearance for a soft band device or a copy of the prescribing physician's original prescription with surgery information for an implanted device, plus a letter of medical necessity from the treating audiologist. If the requested identical replacement sound processor is under warranty, prior approval is not required.

How to Submit

Please submit your request to Trillium Health Resources

Resources

Alkaline battery for use with cochlear implant device, any size, replacement, each

Service Code
L8622 (HCPCS) Alkaline battery for use with cochlear implant device, any size, replacement, 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.

How to Submit

Please submit your request to Trillium Health Resources

Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each

Service Code
L8623 (HCPCS) Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, 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.

How to Submit

Please submit your request to Trillium Health Resources