S1263
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Complex/complete decongestive therapy (CDT);and
- Compression garments;and
- Manual lymphatic drainage;and
- Brachioplasty is consideredmedically necessarywhen done in the presence of a significant functional impairment (for example, redundant or excessive skin is interfering with activities of daily living or causing persistent dermatitis, cellulitis, or skin ulcerations) and the impairment persists despite optimal medical management (for example, topical or systemic treatments for infection) and the procedure is reasonably expected to improve that significant functional impairment.
- Buttock or thigh lifts are consideredmedically necessarywhen there is a significant functional impairment (for example, redundant or excessive skin is interfering with activities of daily living or causing persistent dermatitis, cellulitis, or skin ulcerations) and the impairment persists despite optimal medical management (for example, topical or systemic treatments for infection) and the procedure is reasonably expected to improve that significant functional impairment.
- Correction of congenital abnormalities of the trunk and groin are consideredmedically necessarywhen there is evidence of a significant functional impairment and the procedure can be reasonably expected to improve the functional impairment.
1 Active Policy
ANTHEM-MP-A050277 — ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
Related Codes
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