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
Osteotomy, mandible, segmental;
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
Osteotomy, mandible, segmental; with genioglossus advancement
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
Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard)
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
Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)
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
Osteoplasty, facial bones; reduction
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
Graft, bone; nasal, maxillary or malar areas (includes obtaining 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
Graft, bone; mandible (includes obtaining 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
Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining 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
Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)
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
Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)
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
Arthroplasty, temporomandibular joint, with allograft
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
Arthroplasty, temporomandibular joint, with prosthetic joint replacement
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
Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate)
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 mandible or maxilla, subperiosteal implant; partial
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 mandible or maxilla, subperiosteal implant; complete
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 condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)
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 mandible or maxilla, endosteal implant (eg, blade, cylinder); partial
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
Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete
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
Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (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 of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia)
How to Submit
N/A - No authorization is required
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