Does 11970 require prior authorization?

No, 11970 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 11970?

Medicare facility rate: $517.38. Non-facility rate: $517.38. Work RVU: 7.30.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

7.30

Facility

$517.38

Non-Facility

$517.38

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; medical records documentation used for reviews (general statement from policy).
Documentation of prior Mastectomy (operative report, pathology report, or other clinical record) to support reconstruction related to Mastectomy and WHCRA entitlement.
Clinical documentation supporting diagnosis when reconstruction is for congenital disorders or severe breast disfigurement (e.g., diagnosis of Poland syndrome, Turner syndrome, amastia, radiation-related disfigurement).
When requesting correction of inverted nipples, documentation of either: a documented history of chronic nipple discharge, bleeding, scabbing, or ductal infection; OR evidence that the inverted nipple is the result of a congenital anomaly.

Treatment for post-mastectomy complications including postoperative infection(s).
Breast reconstruction after Mastectomy with or without a diagnosis of cancer in accordance with the Women's Health and Cancer Rights Act of 1998 (reconstruction of the breast on which the Mastectomy was performed).
Surgery and reconstruction of the contralateral breast to produce a symmetrical appearance, including nipple tattooing (per WHCRA).
Prostheses (implanted and/or external) related to breast reconstruction post-mastectomy (per WHCRA).
Treatment of physical complications of Mastectomy, including lymphedema (including complex decongestive physiotherapy (CDP), lymphedema pumps [considered durable medical equipment], compression lymphedema sleeves [considered a prosthetic device], elastic bandages and wraps associated with medically necessary treatments for complications of lymphedema).
Breast reconstruction during or post Mastectomy and reconstruction for treatment of congenital disorder (e.g., Poland syndrome, Turner syndrome) or severe breast disfigurement (e.g., amastia, radiation) when considered reconstructive and medically necessary in accordance with InterQual CP: Procedures, Breast Reconstruction.

AMBETTER-CP.MP.95 — Gender-Affirming Procedures

AETNA-CPB-0272 — Pectus Excavatum and Poland's Syndrome: Surgical Correction

UMR-POL-UMR-breast-reconstruction — Breast Reconstruction

SUREST-POL-SUREST-breast-reconstruction — Breast Reconstruction

HUMANA-BREAST-RECONSTRUCTION-OK-MEDICAID — Breast Reconstruction - MEDICAID - OKLAHOMA

Ask Verity about documentation requirements, denial risks, or coverage in your state.