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

Knee blocks with hardware, pair

Service Code
W4141 (HCPCS) Knee blocks with hardware, pair
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Shoe holders with hardware, pair

Service Code
W4143 (HCPCS) Shoe holders with hardware, pair
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

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/Legrest cradle, each

Service Code
W4144 (HCPCS) Foot/Legrest cradle, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Manual tilt-in-space option, each

Service Code
W4145 (HCPCS) Manual tilt-in-space option, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Multi-adjustable tray, each

Service Code
W4150 (HCPCS) Multi-adjustable tray, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Growth kit, each

Service Code
W4152 (HCPCS) Growth kit, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Tracheostomy ties, twill, each

Service Code
W4153 (HCPCS) Tracheostomy ties, twill, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Adductor pads with hardware, pari

Service Code
W4155 (HCPCS) Adductor pads with hardware, pari
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Low profile gastrostomy extension/replacement kit for continuous feeding, each

Service Code
W4211 (HCPCS) Low profile gastrostomy extension/replacement kit for continuous feeding, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Low profile gastrostomy extension/replacement kit for bolus feeding, each

Service Code
W4212 (HCPCS) Low profile gastrostomy extension/replacement kit for bolus feeding, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Tracheostomy ties, twill, each

Service Code
W4670 (HCPCS) Tracheostomy ties, twill, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

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 battery for portable suction pump adaptic and transparent type such as Tegaderm or Opsite for use with external insulin pump, each

Service Code
W4678 (HCPCS) Replacement battery for portable suction pump adaptic and transparent type such as Tegaderm or Opsite for use with external insulin pump, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Single point cane for weights 251# to 500#

Service Code
W4688 (HCPCS) Single point cane for weights 251# to 500#
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Quad cane for weights 251# to 500#

Service Code
W4689 (HCPCS) Quad cane for weights 251# to 500#
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Underarm crutches for weights 251# to 500#

Service Code
W4690 (HCPCS) Underarm crutches for weights 251# to 500#
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Fixed-height forearm crutches for weights to 600#

Service Code
W4691 (HCPCS) Fixed-height forearm crutches for weights to 600#
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Glides/skis for use with walker

Service Code
W4695 (HCPCS) Glides/skis for use with walker
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

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/Legrest cradle, each

Service Code
W4713 (HCPCS) Foot/Legrest cradle, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Swingaway special construction footrests for weights 401# and greater, pair

Service Code
W4714 (HCPCS) Swingaway special construction footrests for weights 401# and greater, pair
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Swingaway reinforced leg rest, elevating, for weights 301# to 400#, pair

Service Code
W4715 (HCPCS) Swingaway reinforced leg rest, elevating, for weights 301# to 400#, pair
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity