11960
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
11.20
Facility
$948.25
Non-Facility
$948.25
Documentation Required
- Refer to the member specific benefit plan document and applicable federal or state mandates for additional documentation requirements.
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
- Documentation that the physical abnormality and/or physiological abnormality is causing a Functional Impairment that requires correction (per reconstructive criteria).
- Documentation that the proposed treatment is of proven efficacy and is deemed likely to significantly improve or restore the individual's physiological function.
Key Coverage Criteria
- A procedure is considered reconstructive and medically necessary when all of the following criteria are met: - There is documentation that the physical abnormality and/or physiological abnormality is causing a Functional Impairment that requires correction; and - The proposed treatment is of proven efficacy and is deemed likely to significantly improve or restore the individual's physiological function
- Microtia repair is considered reconstructive although no Functional Impairment may be documented.
- Tissue Transfer (Flap) Repair: Flap repair is considered reconstructive and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Tissue Transfer (Flap).
- Breast reconstruction following a mastectomy, and reconstruction of the non-affected breast to achieve symmetry; other services required by the Women's Health and Cancer Rights Act of 1998 (including breast prostheses and treatment of complications) are provided in the same manner and at the same level as those for any other covered health care service.
- Removal of a leaking or defective silicone breast prosthesis is a covered health care service (treatment of complications of an otherwise non-covered original service may be covered limited to treatment of the complication).
- Surgical repair of severe pectus excavatum deformities that cause functional deficit when done for medical reasons in members who meet all of the following criteria:
9 Active Policies
AMBETTER-CP.MP.95 — Gender-Affirming Procedures
AETNA-CPB-0272 — Pectus Excavatum and Poland's Syndrome: Surgical Correction
UHC-POL-cosmetic-and-reconstructive-procedures — Cosmetic and Reconstructive Procedures
AETNA-CPB-0244 — Skin and Soft Tissue Substitutes
BCBSIL-SUR716.001 — Cosmetic and Reconstructive Procedures
Related Codes
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