S21.009S — Unspecified open wound of unspecified breast, sequela
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Removal of implantspartially or completely filledwithSilicone Gelis consideredmedically necessarywhen there is documented implant rupture (that is, using mammography, ultrasound, or MRI).
- Removal of aSilicone Gel filled,Saline filled or Alternativeâimplant is consideredmedically necessaryfor any of the following:
- Infection of the implant or surrounding tissue;or
- Implant exposure/extrusion;or
- Pain related to Baker Class IV capsular contracture;or
- Confirmed cases of breast implant-associated anaplastic large cell lymphoma;or
1 Active Policy
ANTHEM-SURG.00023 — SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
Related Codes
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