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
Repair or advancement of profundus tendon, with intact superficialis tendon; secondary with free graft (includes obtaining graft), each tendon
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Repair or advancement of profundus tendon, with intact superficialis tendon; secondary without free graft, each tendon
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Removal of synthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining graft), each rod
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendon
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Excision of extensor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Removal of synthetic rod and insertion of extensor tendon graft (includes obtaining graft), hand or finger, each rod
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Repair, extensor tendon, finger, primary or secondary; with free graft (includes obtaining graft) each tendon
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); using local tissue(s), including lateral band(s), each finger
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); with free graft (includes obtaining graft), each finger
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger)
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger)
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Repair of extensor tendon, distal insertion, primary or secondary; with free graft (includes obtaining graft)
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Realignment of extensor tendon, hand, each tendon
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Tenolysis, flexor tendon; palm OR finger, each tendon
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Tenolysis, flexor tendon; palm AND finger, each tendon
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Tenolysis, extensor tendon, hand OR finger, each tendon
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Tenolysis, complex, extensor tendon, finger, including forearm, each tendon
Authorization Guidelines
If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
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