11921
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
1.88
Facility
$115.90
Non-Facility
$233.47
Documentation Required
- All documentation must be maintained in the patient's medical record, legible, include patient identifiers (e.g., full name, dates of service), and contain the legible signature of the responsible physician or non-physician practitioner to support medical necessity.
- Use diagnosis code Z41.1 (Encounter for cosmetic surgery) for cosmetic procedures and apply GY modifier for statutorily excluded or non-covered services when submitting for denial; include condition code 21 for no-payment non-covered claims as appropriate.
- For removal of breast implants, the medical record must describe the condition supporting implant removal as medically reasonable and necessary.
- For breast reduction, document height, weight, Body Surface Area (BSA), clinical evaluation of macromastia signs/symptoms, prior therapies and responses, operative report with weight removed from each breast, and pathology report with weight from each breast.
Key Coverage Criteria
- Reconstructive surgery is covered for abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease when performed to improve function or approximate normal appearance.
- Removal of breast implant(s) is covered when the medical record documents a condition that makes removal medically reasonable and necessary.
- Breast reduction (reduction mammoplasty) is covered when clinical evaluation documents macromastia with signs/symptoms, height/weight and BSA are recorded, and back/neck/shoulder pain is unrelieved by at least 6 months of conservative treatment, with operative and pathology reports documenting the weight of tissue removed from each breast.
- Mastectomy for gynecomastia is covered when glandular breast tissue consistent with true gynecomastia is documented, Grade III or IV classification (ASPS) is present, hormonal causes have been excluded by appropriate labs, medical treatment has failed for at least 6 months, and gynecomastia has persisted for at least 1 year.
- Rhinoplasty is covered when medical record documents a condition requiring the procedure (including chronic nasal obstruction) with documentation of the cause of obstruction, appropriate diagnostic exams (e.g., anterior rhinoscopy, endoscopy, Cottle maneuver, CT) and prior conservative treatments with duration; septoplasty documentation must include surgical/pathology report when postoperative.
- Rhinoplasty/Septoplasty to correct septal deformity that interferes with effective CPAP use is covered when medical management and duration of conservative therapy are documented showing interference with CPAP for treatment of an obstructive sleep disorder.
20 Active Policies
A58774 — Billing and Coding: Cosmetic and Reconstructive Surgery
J05
L39051 — Cosmetic and Reconstructive Surgery
J05
L39506 — Cosmetic and Reconstructive Surgery
UMR-POL-UMR-breast-reconstruction — Breast Reconstruction
SUREST-POL-SUREST-breast-reconstruction — Breast Reconstruction
Related Codes
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