0419T — Dstrj neurofibroma xtnsv
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documented diagnosis of a craniofacial anomaly in the medical record.
- Clinical documentation demonstrating that the surgery, device, or procedure is medically necessary to improve a functional impairment caused by the craniofacial anomaly.
- For scleral contact lenses: documentation of ocular impressions (one per eye) and related office visits/tests as clinically indicated.
- For hearing devices: documentation supporting need, type of device (e.g., BTE, ITE, bone conduction, cochlear implant), and frequency eligibility (every two years).
Key Coverage Criteria
- Medically necessary reconstructive services intended to restore physical appearance of body structures damaged by trauma.
- Applies to policies amended, delivered, issued, or renewed on or after 2025-01-01 for Individual and family PPO/HMO/POS; Student plans; Group (Small Group, Mid-Market, Large Group fully insured PPO/HMO/POS); and Medicaid in Illinois.
- Reconstructive surgery and related medical care for any age with a diagnosed craniofacial anomaly when medically necessary to improve a functional impairment resulting from the anomaly.
- Annual coverage of scleral contact lenses (including coatings), office visits, an ocular impression of each eye, and any additional tests or procedures medically necessary for craniofacial patients.
- Coverage every two years for two hearing aids and two hearing aid molds for each ear, including behind-the-ear, in-the-ear, wearable bone conduction, surgically implanted bone conduction services, and cochlear implants.
- Dental care related to reconstructive treatment of craniofacial anomalies (when medically necessary to address functional impairment).
5 Active Policies
BCBSIL-SUR716.001 — Cosmetic and Reconstructive Procedures
BCBSMT-SUR716.001 — Cosmetic and Reconstructive Procedures
BCBSNM-SUR716.001 — Cosmetic and Reconstructive Procedures
BCBSOK-SUR716.001 — Cosmetic and Reconstructive Procedures
SUR716.001 — Cosmetic and Reconstructive Procedures
Related Codes
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