38308
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
6.64
Facility
$447.57
Non-Facility
$447.57
Documentation Required
- Pertinent history documenting risk factors (e.g., cancer treatment, trauma).
- Physical exam documentation showing localized, progressive edema and asymmetric limb measurements.
- Documentation that other causes of edema were considered and excluded.
- Imaging reports (MRI, CT, ultrasound, or lymphoscintigraphy) when imaging is used to clarify diagnosis.
Key Coverage Criteria
- Medically necessary reconstructive services intended to restore the physical appearance of body structures damaged by trauma.
- When an enrollee elects reconstruction after a mastectomy, coverage for surgery and reconstruction of the breast on which the mastectomy was performed is required.
- Coverage for surgery and reconstruction of the contralateral breast when performed to produce a symmetrical appearance is required.
- Coverage for prostheses related to mastectomy and reconstruction is required.
- Coverage for physical complications of all stages of a mastectomy, including lymphedema, is required.
- Mandated coverage applies to HCSC members residing in Arkansas enrolled in Fully Insured Group, Student, Small Group, Mid‑Market, Large Group, HMO, EPO, PPO, and POS products.
5 Active Policies
BCBSIL-SUR701.024 — Surgical Treatments for Breast Cancer-Related Lymphedema
BCBSMT-SUR701.024 — Surgical Treatments for Breast Cancer-Related Lymphedema
BCBSNM-SUR701.024 — Surgical Treatments for Breast Cancer-Related Lymphedema
BCBSOK-SUR701.024 — Surgical Treatments for Breast Cancer-Related Lymphedema
SUR701.024 — Surgical Treatments for Breast Cancer-Related Lymphedema
Related Codes
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