19372
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical justification that the service meets generally accepted standards of medical practice.
- Providers may request a copy of the medical necessity criteria by calling Provider Services at 877-856-5707 (TTY: 711), Monday-Friday, 7AM to 8PM EST or by emailing OHMCDUM@humana.com
- No specific documentation requirements, required medical records, test results, or clinical documentation are stated in this excerpt
- No documentation requirements are specified in this excerpt.
Key Coverage Criteria
- Breast reconstruction services when determined medically necessary on a case-by-case basis based on the information provided about the member's health status.
- Policy applies to eligible Humana Healthy Horizons Medicaid members needing breast reconstruction as evaluated by Medicaid clinical delivery associates.
- Breast reconstruction surgery to rebuild a breast's shape following a mastectomy
- Breast reconstruction surgery to rebuild a breast's shape following trauma
- Reconstruction may be performed immediately (at time of mastectomy)
- Reconstruction may be delayed (performed at a later date after mastectomy/trauma)
1 Active Policy
HUMANA-BREAST-RECONSTRUCTION-OH-MEDICAID — Breast Reconstruction - MEDICAID - OHIO
Related Codes
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