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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

Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies)

Service Code
21147 (CPT) Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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 II; anterior intrusion (eg, Treacher-Collins Syndrome)

Service Code
21150 (CPT) Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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 II; any direction, requiring bone grafts (includes obtaining autografts)

Service Code
21151 (CPT) Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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 III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I

Service Code
21154 (CPT) Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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 III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I

Service Code
21155 (CPT) Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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 III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I

Service Code
21159 (CPT) Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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 III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I

Service Code
21160 (CPT) Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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 superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts)

Service Code
21172 (CPT) Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

N/A - No authorization is required

Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts)

Service Code
21175 (CPT) Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

N/A - No authorization is required

Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material)

Service Code
21179 (CPT) Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

N/A - No authorization is required

Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts)

Service Code
21180 (CPT) Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

N/A - No authorization is required

Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial

Service Code
21181 (CPT) Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

N/A - No authorization is required

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less

Service Code
21182 (CPT) Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

N/A - No authorization is required

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting grea

Service Code
21183 (CPT) Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting grea
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

N/A - No authorization is required

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting grea

Service Code
21184 (CPT) Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting grea
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)

Service Code
21188 (CPT) Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

N/A - No authorization is required

Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft

Service Code
21193 (CPT) Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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 of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)

Service Code
21194 (CPT) Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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 of mandibular rami and/or body, sagittal split; without internal rigid fixation

Service Code
21195 (CPT) Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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 of mandibular rami and/or body, sagittal split; with internal rigid fixation

Service Code
21196 (CPT) Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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