19333
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- No specific documentation requirements (medical records, imaging, test results, or operative notes) are specified in this document excerpt
- Refer to CMS Medicare Coverage Database for the most current applicable CMS National Coverage Determination (NCD)/Local Coverage Determination (LCD)/Local Coverage Article (LCA).
- Refer to the CMS website for the most current applicable CMS Online Manual System (IOMs) and Transmittals.
- Documentation requirements for coverage (e.g., medical records, clinical notes, test results) are those specified in the applicable MAC LCD(s); this excerpt contains no additional, explicit documentation requirements.
Key Coverage Criteria
- No explicit covered indications are listed in this excerpt. Coverage determinations are delegated to the applicable MAC LCDs and CMS NCDs/LCAs.
- Humana and subsidiaries apply a Medicare Administrative Contractor's (MAC's) LCD to all requests (both Part A and Part B services) within the MAC's applicable geographic jurisdiction.
- Breast reconstruction following mastectomy (NCD 140.2) — indicated as a covered topic by the referenced NCD title.
- Reconstructive surgery of the breast or other body parts when performed for medical/reconstructive reasons rather than cosmetic reasons (inferred from LCD titles 'Cosmetic and Reconstructive Surgery' and 'Plastic Surgery').
- Cosmetic and Reconstructive Surgery
- Breast reconstruction surgery to rebuild a breast's shape following a mastectomy
1 Active Policy
HUMANA-BREAST-RECONSTRUCTION-MA — Breast Reconstruction - Medicare Advantage
Related Codes
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