S2067 — Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (diep) flap(s) and/or gluteal artery perforator (gap) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral
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
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; medical records documentation used for reviews (general statement from policy).
- Documentation of prior Mastectomy (operative report, pathology report, or other clinical record) to support reconstruction related to Mastectomy and WHCRA entitlement.