21230
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
10.89
Facility
$659.67
Non-Facility
$659.67
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.
- All documentation must be maintained in the patient’s medical record, be legible, contain complete patient identification and dates of service, include the legible signature of the responsible physician or non-physician practitioner, and support the medical necessity of the services.
- For removal of breast implants, the medical record must describe the condition that supports implant removal as medically reasonable and necessary.
Key Coverage Criteria
- Reconstructive surgery is covered for abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease when performed to improve function or approximate a normal appearance.
- Removal of breast implant(s) is covered when the medical record documents the condition(s) that make removal medically reasonable and necessary.
- Breast reduction (reduction mammaplasty) is covered for macromastia causing back, neck, or shoulder pain that is unrelieved by at least 6 months of conservative analgesia, supportive measures, and physical therapy.
- Mastectomy for gynecomastia is covered when glandular breast tissue is confirmed by physical exam and/or mammography, gynecomastia persists despite correction of underlying causes and medical therapy, is ASPS Grade III or IV, hormonal causes have been excluded by appropriate labs, and criteria regarding persistence after treatment (including at least 6 months of unsuccessful medical treatment and persistence for at least one year) are met.
- Tattooing or skin color-correction procedures are covered when performed for reconstructive reasons (e.g., post-mastectomy or trauma) documented in the progress notes.
- Punch graft hair transplantation is covered for reconstructive purposes when pre-operative photographs are available upon contractor request.
14 Active Policies
AMBETTER-CP.MP.31 — Cosmetic and Reconstructive Procedures
A56658 — Billing and Coding: Cosmetic and Reconstructive Surgery
A59299 — Billing and Coding: Cosmetic and Reconstructive Surgery
L39506 — Cosmetic and Reconstructive Surgery
L33428 — Cosmetic and Reconstructive Surgery
Related Codes
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