26989
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation of extensive medical screening demonstrating suitability for transplantation
- Documentation of psychosocial screening demonstrating suitability for transplantation
- Studies presented must represent one or more intended clinical uses of the technology in the intended population.
- Comparators in studies must be effective and appropriate alternatives at comparable intensity; supportive care or surveillance may be appropriate comparators for some conditions.
Key Coverage Criteria
- Facial transplantation to restore appearance and psychosocial function when traditional reconstructive options are inadequate.
- Hand transplantation to restore functional abilities (e.g., grasping, lifting) when prosthetics or other interventions are not suitable or effective.
- Composite tissue transplantation to improve specific functional deficits (e.g., blinking, mouth closure) aimed at quality-of-life improvements rather than life‑saving benefit.
- Consider hand transplantation only for candidates who can withstand substantial physical and mental challenges associated with the procedure.
- Hand and face allotransplantation as a surgical treatment option for qualifying patients
- Composite tissue allotransplantation of the face for individuals with severe facial disfigurement due to burns or trauma.
6 Active Policies
SUR703.052 — Composite Tissue Allotransplantation of the Hand and Face
ANTHEM-MP-E001867 — TRANS.00040 Hand Transplantation
BCBSIL-SUR703.052 — Composite Tissue Allotransplantation of the Hand and Face
BCBSMT-SUR703.052 — Composite Tissue Allotransplantation of the Hand and Face
BCBSNM-SUR703.052 — Composite Tissue Allotransplantation of the Hand and Face
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