Does 69310 require prior authorization?

No, 69310 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 69310?

Medicare facility rate: $1037.10. Non-facility rate: $1037.10. Work RVU: 10.70.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

10.70

Facility

$1037.10

Non-Facility

$1037.10

For reconstruction claimed to prevent inability to use eyewear: frontal, lateral, and posterior photographs with the individual's eyewear being worn that demonstrate the external ear deformity is preventing the functional ability to use eyewear for correction of a current visual deficit (explicitly required by policy).
For indications involving hearing (reconstruction expected to improve hearing, reconstruction necessary to allow use of a conventional air conduction hearing aid, or ear molding for congenital malformation with functional hearing impairment): clinical documentation of congenital external ear malformation and documentation of functional hearing impairment (e.g., audiologic evaluation/audiogram, hearing loss assessment, and documentation that hearing is expected to improve or that ear anatomy prevents use of a conventional air-conduction hearing aid).
For claims involving cochlear implant facilitation: documentation that external ear anatomy interferes with placement/usage of cochlear device microphone and that reconstruction is required to facilitate device use (clinical notes, device evaluation).

External ear reconstruction for the treatment of an external ear deformity or the absence of an external ear is medically necessary when ANY of the following criteria is met: hearing is expected to improve.
External ear reconstruction for the treatment of an external ear deformity or the absence of an external ear is medically necessary when ANY of the following criteria is met: reconstruction is necessary to allow the use of a conventional air conduction hearing aid.
External ear reconstruction for the treatment of an external ear deformity or the absence of an external ear is medically necessary when ANY of the following criteria is met: frontal, lateral, and posterior photographs with eyewear being worn demonstrate that the external ear deformity is preventing the functional ability to use eyewear for the correction of a current visual deficit.
Non-surgical external ear molding is medically necessary for a congenital external ear malformation in an individual with a functional impairment of hearing.
CPT 69310 (reconstruction of external auditory canal/meatoplasty) is considered medically necessary when the applicable policy criteria are met (e.g., for stenosis due to injury or infection).
CPT 69320 (reconstruction external auditory canal for congenital atresia, single stage) is considered medically necessary when the applicable policy criteria are met.

CIGNA-0335 — Otoplasty and External Ear Reconstruction - (0335)

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