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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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12465 Results

Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)

Service Code
20979 (CPT) Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency

Service Code
20982 (CPT) Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation

Service Code
20983 (CPT) Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure)

Service Code
20985 (CPT) Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Unlisted procedure, musculoskeletal system, general

Service Code
20999 (CPT) Unlisted procedure, musculoskeletal system, general
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Arthrotomy, temporomandibular joint

Service Code
21010 (CPT) Arthrotomy, temporomandibular joint
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm

Service Code
21011 (CPT) Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greater

Service Code
21012 (CPT) Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greater
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 2 cm

Service Code
21013 (CPT) Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 2 cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); 2 cm or greater

Service Code
21014 (CPT) Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); 2 cm or greater
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; less than 2 cm

Service Code
21015 (CPT) Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; less than 2 cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; 2 cm or greater

Service Code
21016 (CPT) Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; 2 cm or greater
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of bone (eg, for osteomyelitis or bone abscess); mandible

Service Code
21025 (CPT) Excision of bone (eg, for osteomyelitis or bone abscess); mandible
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s)

Service Code
21026 (CPT) Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia)

Service Code
21029 (CPT) Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage

Service Code
21030 (CPT) Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of torus mandibularis

Service Code
21031 (CPT) Excision of torus mandibularis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of maxillary torus palatinus

Service Code
21032 (CPT) Excision of maxillary torus palatinus
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of malignant tumor of maxilla or zygoma

Service Code
21034 (CPT) Excision of malignant tumor of maxilla or zygoma
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of benign tumor or cyst of mandible, by enucleation and/or curettage

Service Code
21040 (CPT) Excision of benign tumor or cyst of mandible, by enucleation and/or curettage
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required