69090
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- 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).
Key Coverage Criteria
- the procedure is reasonably expected to improve the functional impairment;and
- an audiogram documents a loss of at least 15 decibels in the affected ear(s).
- Facial plastic surgery is consideredmedically necessarywhen required tocorrect a significant functional impairmentandthe procedure can be reasonably expected to improve the functional impairment. Examples include, but are not limited to, reconstructive procedures which correct or improve a significant functional impairment of speech, nutrition, control of secretions, protection of the airway, or corneal protection.
- Facial plastic surgery is consideredreconstructivewhen intended to address a significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.Note:The initial restoration may be completed in stages.
- Otoplasty is consideredmedically necessarywhen performed to surgically correct a physical structure or absence of a physical structure that is causing hearing loss, or intended to facilitate the use of a hearing aid or device whenbothof the following criteria are met:
- Otoplasty is consideredreconstructivewhen intended to restore a significantly abnormal external ear or auditory canal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.
7 Active Policies
ANTHEM-MP-A050276 — ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
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
Related Codes
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