15786
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
2.03
Facility
$118.91
Non-Facility
$232.14
Documentation Required
- The provided text does not specify any required medical records, test results, or other documentation requirements.
- Documentation demonstrating the presence of a functional impairment (evidence of a direct and measurable reduction in physical performance of an organ or body part).
- Medical records supporting the underlying diagnosis or reason for reconstruction (e.g., bodily injury, congenital condition/anomaly, infection, or other disease of the involved part).
- Documentation of medical necessity for the reconstructive procedure.
Key Coverage Criteria
- It is generally performed to improve or restore bodily function when an objective functional impairment present.
- - Lesion is ulcerated (regardless of anatomical location).
- Cosmetic surgery is performed to reshape normal structures of the body in order to improve or change appearance or self-esteem.
- Reconstructive surgery is performed on abnormal structures of the body, caused by congenital (occurring at birth) defects, developmental abnormalities, trauma, infection, tumors or disease.
- Scar revision is performed to correct, remove or improve the tissue that forms as skin heals after an injury or surgery.
- Humana members may be eligible under the Plan for medically necessary reconstructive surgery due to bodily injury when a functional impairment is present.
14 Active Policies
AMBETTER-CP.MP.95 — Gender-Affirming Procedures
HUMANA-COSMETIC-AND-RECONSTRUCTIVE-SURGERY-SC-MEDICAID — Cosmetic and Reconstructive Surgery - MEDICAID - SOUTH CAROLINA
HUMANA-COSMETIC-AND-RECONSTRUCTIVE-SURGERY-KY-MEDICAID — Cosmetic and Reconstructive Surgery - MEDICAID - KENTUCKY
ANTHEM-MP-A050278 — Last Review Date
Related Codes
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