21245
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
12.79
Facility
$866.75
Non-Facility
$1286.27
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.
- Preoperative photographs may be required to support justification for abdominoplasty/panniculectomy and should be supplied upon request.
- Rhinoplasty requires photographic documentation (frontal, lateral, and worm's eye views) when submitted for coverage as reconstructive.
- Medical records must document chronic intertrigo signs and that appropriate medical therapy was administered for panniculus-related symptoms and that symptoms recurred over or were refractory for 3 months.
Key Coverage Criteria
- 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.
- Panniculectomy may be covered after significant weight loss when the individual has maintained a stable weight for at least 3 to 6 months and, if weight loss was from bariatric surgery, when performed at least 18 months after bariatric surgery with weight stable for the most recent 3 to 6 months.
8 Active Policies
AMBETTER-CP.MP.202 — Orthognathic Surgery
A56658 — Billing and Coding: Cosmetic and Reconstructive Surgery
L33428 — Cosmetic and Reconstructive Surgery
CIGNA-0585 — Dental Implants - (0585)
HUMANA-ORTHOGNATHIC-SURGERY-MA — Orthognathic Surgery - Medicare Advantage
Related Codes
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