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
Impression and custom preparation; nasal prosthesis
How to Submit
N/A - No authorization is required
Impression and custom preparation; facial prosthesis
How to Submit
N/A - No authorization is required
Unlisted maxillofacial prosthetic procedure
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
Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)
How to Submit
N/A - No authorization is required
Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
How to Submit
N/A - No authorization is required
Injection procedure for temporomandibular joint arthrography
How to Submit
N/A - No authorization is required
Genioplasty; augmentation (autograft, allograft, prosthetic material)
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
Genioplasty; sliding osteotomy, single piece
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin)
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
Augmentation, mandibular body or angle; prosthetic material
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
Reduction forehead; contouring only
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
Reduction forehead; contouring and setback of anterior frontal sinus wall
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft)
Authorization Guidelines
The following information shall be submitted with each prior approval request:
- a. The location and cause of the defect;
- b. Pre-operative photographs;
- c. CPT codes describing the procedures to be performed; and
- d. Supporting documentation that the treatment can reasonably be expected to
improve the impairment.
How to Submit
Please submit your request to Trillium Health Resources
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