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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

Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach

Service Code
21260 (CPT) Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach
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

Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach

Service Code
21261 (CPT) Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach
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

Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement

Service Code
21263 (CPT) Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach

Service Code
21267 (CPT) Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach

Service Code
21268 (CPT) Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach
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

Malar augmentation, prosthetic material

Service Code
21270 (CPT) Malar augmentation, prosthetic material
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

Secondary revision of orbitocraniofacial reconstruction

Service Code
21275 (CPT) Secondary revision of orbitocraniofacial reconstruction
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Medial canthopexy (separate procedure)

Service Code
21280 (CPT) Medial canthopexy (separate procedure)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

Lateral canthopexy

Service Code
21282 (CPT) Lateral canthopexy
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach

Service Code
21295 (CPT) Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach
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

Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach

Service Code
21296 (CPT) Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach
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

Unlisted craniofacial and maxillofacial procedure

Service Code
21299 (CPT) Unlisted craniofacial and maxillofacial procedure
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

Closed treatment of nasal bone fracture; without stabilization

Service Code
21315 (CPT) Closed treatment of nasal bone fracture; without stabilization
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Closed treatment of nasal bone fracture; with stabilization

Service Code
21320 (CPT) Closed treatment of nasal bone fracture; with stabilization
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Open treatment of nasal fracture; uncomplicated

Service Code
21325 (CPT) Open treatment of nasal fracture; uncomplicated
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation

Service Code
21330 (CPT) Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Open treatment of nasal fracture; with concomitant open treatment of fractured septum

Service Code
21335 (CPT) Open treatment of nasal fracture; with concomitant open treatment of fractured septum
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Open treatment of nasal septal fracture, with or without stabilization

Service Code
21336 (CPT) Open treatment of nasal septal fracture, with or without stabilization
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Closed treatment of nasal septal fracture, with or without stabilization

Service Code
21337 (CPT) Closed treatment of nasal septal fracture, with or without stabilization
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Open treatment of nasoethmoid fracture; without external fixation

Service Code
21338 (CPT) Open treatment of nasoethmoid fracture; without external fixation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required