19324
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of attempted conservative therapy and evidence of its failure when required (or justification that conservative therapy is not standard of care or is contraindicated).
- For skin tag removal: documentation of anatomical location (affecting eyesight or area of friction) and evidence of repeated irritation and bleeding.
- For scar/keloid revision: documentation of pain unresponsive to conservative therapy, recurrent infection, unstable or friable tissue, or objective functional impairment.
- Photographs may be requested, if applicable.
Key Coverage Criteria
- Removal of implantspartially or completely filledwithSilicone Gelis consideredmedically necessarywhen there is documented implant rupture (that is, using mammography, ultrasound, or MRI).
- Removal of aSilicone Gel filled,Saline filled or Alternativeâimplant is consideredmedically necessaryfor any of the following:
- Infection of the implant or surrounding tissue;or
- Implant exposure/extrusion;or
- Pain related to Baker Class IV capsular contracture;or
- Confirmed cases of breast implant-associated anaplastic large cell lymphoma;or
3 Active Policies
AMBETTER-CP.MP.31 — Cosmetic and Reconstructive Procedures
AMBETTER-CP.MP.95 — Gender-Affirming Procedures
ANTHEM-SURG.00023 — SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
Related Codes
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