21196
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
20.31
Facility
$1296.62
Non-Facility
$1296.62
Documentation Required
- This policy provides billing, coding, and guideline information that complements the Local Coverage Determination (LCD) 'Cosmetic and Reconstructive Surgery' L33428; the full policy content is not included here, so specific documentation requirements (e.g., medical records, prior authorizations, forms) are not available in the provided excerpt.
- If LAUP, Somnoplasty™, Pillar Procedure™/palatal implant, or other non-covered palatal procedures are billed for denial purposes, bill as CPT 42299 (unlisted procedure, palate/uvula) and include the procedure name (e.g., 'LAUP', 'Somnoplasty', 'Pillar Procedure', 'palatal implant') in the electronic narrative field 2400/SV101-7 (CMS-1500 line 19 equivalent).
- Hospital outpatient departments should use HCPCS code C9727 for palatal implant procedures (Pillar Procedure™) when billing; such claims will be denied as not proven effective.
Key Coverage Criteria
- Surgical treatment of obstructive sleep apnea (OSA) is considered for coverage only when it meets the coverage indications, limitations, and medical necessity requirements described in LCD L34526.
- Dermabrasion is covered when used to correct skin defects resulting from traumatic injury, prior surgery, or disease.
- Septoplasty is covered for septal deviation causing nasal airway obstruction unresponsive to a recent trial of conservative medical management lasting at least 6 weeks.
- Septoplasty is covered for recurrent sinusitis secondary to a deviated septum that does not resolve after appropriate medical and antibiotic therapy.
- Reconstructive surgery is covered for abnormal structures caused by congenital defects, developmental abnormalities, trauma, surgery, infection, tumors, or disease when performed to improve function or approximate a normal appearance.
- Panniculectomy is medically necessary when the panniculus hangs below the level of the pubis and medical records document chronic intertrigo (skin irritation, infection, or chafing on opposed surfaces) that consistently recurs over 3 months while receiving appropriate medical therapy or remains refractory to appropriate medical therapy for 3 months.
16 Active Policies
A56905 — Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA)
J05
L34526 — Surgical Treatment of Obstructive Sleep Apnea (OSA)
J05
L33428 — Cosmetic and Reconstructive Surgery
HUMANA-OBSTRUCTIVE-SLEEP-APNEA-AND-OTHER-SLEEP-RELATED-BREATHING-DISORDERS-SURGICAL-TREATMENTS-MA — Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Surgical Treatments - Medicare Advantage
Related Codes
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