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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Lithium ion battery for use with cochlear implant or auditory osseointegrated device speech processor, ear level, replacement, each

Service Code
L8624 (HCPCS) Lithium ion battery for use with cochlear implant or auditory osseointegrated device speech processor, ear level, replacement, each
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

1 set of 4 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 controller component, replacement

Service Code
L8628 (HCPCS) Cochlear implant, external controller component, replacement
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

Transmitting coil and cable, integrated, for use with cochlear implant device, replacement

Service Code
L8629 (HCPCS) Transmitting coil and cable, integrated, for use with cochlear implant device, replacement
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

Electrical stimulator supplies (external) for use with implantable neurostimulator, per month

Service Code
L8678 (HCPCS) Electrical stimulator supplies (external) for use with implantable neurostimulator, per month
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

Implantable neurostimulator, pulse generator, any type

Service Code
L8679 (HCPCS) Implantable neurostimulator, pulse generator, any type
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 Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Implantable neurostimulator electrode, each

Service Code
L8680 (HCPCS) Implantable neurostimulator electrode, 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 Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Implantable neurostimulator radiofrequency receiver

Service Code
L8682 (HCPCS) Implantable neurostimulator radiofrequency receiver
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 Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver

Service Code
L8683 (HCPCS) Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
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 Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement

Service Code
L8684 (HCPCS) Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, 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.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Implantable neurostimulator pulse generator, single array, rechargeable, includes extension

Service Code
L8685 (HCPCS) Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
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 Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension

Service Code
L8686 (HCPCS) Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension
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 Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

Service Code
L8687 (HCPCS) Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
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 Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension

Service Code
L8688 (HCPCS) Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension
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 Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

Service Code
L8689 (HCPCS) External recharging system for battery (internal) for use with implantable neurostimulator, replacement 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 Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

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

Service Code
L8691 (HCPCS) Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, 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

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

Service Code
L8692 (HCPCS) Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment
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

External recharging system for battery (external) for use with implantable neurostimulator, replacement only

Service Code
L8695 (HCPCS) External recharging system for battery (external) for use with implantable neurostimulator, replacement 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 Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

External lower extremity sensory prosthetic, cutaneous stimulation of mechanoreceptors proximal to the ankle, per leg

Service Code
L8720 (HCPCS) External lower extremity sensory prosthetic, cutaneous stimulation of mechanoreceptors proximal to the ankle, per 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

Receptor sole for use with L8720, replacement, each

Service Code
L8721 (HCPCS) Receptor sole for use with L8720, replacement, each
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

COVID-19 vaccine administration inside a patient's home; reported only once per individual home, per date of service, when only COVID-19 vaccine administration is performed at the patient's home

Service Code
M0201 (HCPCS) COVID-19 vaccine administration inside a patient's home; reported only once per individual home, per date of service, when only COVID-19 vaccine administration is performed at the patient's home
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