Does 41872 require prior authorization?

No, 41872 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 41872?

Medicare facility rate: $298.94. Non-facility rate: $513.37. Work RVU: 2.93.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

2.93

Facility

$298.94

Non-Facility

$513.37

Documented diagnosis of a craniofacial anomaly in the medical record.
Clinical documentation demonstrating that the surgery, device, or procedure is medically necessary to improve a functional impairment caused by the craniofacial anomaly.
For scleral contact lenses: documentation of ocular impressions (one per eye) and related office visits/tests as clinically indicated.
For hearing devices: documentation supporting need, type of device (e.g., BTE, ITE, bone conduction, cochlear implant), and frequency eligibility (every two years).

Medically necessary reconstructive services intended to restore physical appearance of body structures damaged by trauma.
Applies to policies amended, delivered, issued, or renewed on or after 2025-01-01 for Individual and family PPO/HMO/POS; Student plans; Group (Small Group, Mid-Market, Large Group fully insured PPO/HMO/POS); and Medicaid in Illinois.
Reconstructive surgery and related medical care for any age with a diagnosed craniofacial anomaly when medically necessary to improve a functional impairment resulting from the anomaly.
Annual coverage of scleral contact lenses (including coatings), office visits, an ocular impression of each eye, and any additional tests or procedures medically necessary for craniofacial patients.
Coverage every two years for two hearing aids and two hearing aid molds for each ear, including behind-the-ear, in-the-ear, wearable bone conduction, surgically implanted bone conduction services, and cochlear implants.
Dental care related to reconstructive treatment of craniofacial anomalies (when medically necessary to address functional impairment).

BCBSIL-SUR716.001 — Cosmetic and Reconstructive Procedures

BCBSMT-SUR716.001 — Cosmetic and Reconstructive Procedures

BCBSNM-SUR716.001 — Cosmetic and Reconstructive Procedures

BCBSOK-SUR716.001 — Cosmetic and Reconstructive Procedures

REGENCE-AH35 — Administrative Guidelines to Determine Dental vs Medical Services

Ask Verity about documentation requirements, denial risks, or coverage in your state.