Z44.31 — Encounter for fitting and adjustment of external right breast prosthesis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This policy provides billing, coding, and guideline information that complements the Local Coverage Determination (LCD) 'Cosmetic and Reconstructive Surgery' L33428; the full policy content is not included here, so specific documentation requirements (e.g., medical records, prior authorizations, forms) are not available in the provided excerpt.
- All documentation must be maintained in the patient's medical record, legible, include patient identifiers (e.g., full name, dates of service), and contain the legible signature of the responsible physician or non-physician practitioner to support medical necessity.
- Use diagnosis code Z41.1 (Encounter for cosmetic surgery) for cosmetic procedures and apply GY modifier for statutorily excluded or non-covered services when submitting for denial; include condition code 21 for no-payment non-covered claims as appropriate.
Key Coverage Criteria
- Reconstructive surgery is covered for abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease when performed to improve function or approximate normal appearance.
- Removal of breast implant(s) is covered when the medical record documents a condition that makes removal medically reasonable and necessary.
- Breast reduction (reduction mammoplasty) is covered when clinical evaluation documents macromastia with signs/symptoms, height/weight and BSA are recorded, and back/neck/shoulder pain is unrelieved by at least 6 months of conservative treatment, with operative and pathology reports documenting the weight of tissue removed from each breast.
- Mastectomy for gynecomastia is covered when glandular breast tissue consistent with true gynecomastia is documented, Grade III or IV classification (ASPS) is present, hormonal causes have been excluded by appropriate labs, medical treatment has failed for at least 6 months, and gynecomastia has persisted for at least 1 year.
- Rhinoplasty is covered when medical record documents a condition requiring the procedure (including chronic nasal obstruction) with documentation of the cause of obstruction, appropriate diagnostic exams (e.g., anterior rhinoscopy, endoscopy, Cottle maneuver, CT) and prior conservative treatments with duration; septoplasty documentation must include surgical/pathology report when postoperative.
- Rhinoplasty/Septoplasty to correct septal deformity that interferes with effective CPAP use is covered when medical management and duration of conservative therapy are documented showing interference with CPAP for treatment of an obstructive sleep disorder.
6 Active Policies
A58774 — Billing and Coding: Cosmetic and Reconstructive Surgery
J05
L39051 — Cosmetic and Reconstructive Surgery
J05
A56658 — Billing and Coding: Cosmetic and Reconstructive Surgery
A59299 — Billing and Coding: Cosmetic and Reconstructive Surgery
L39506 — Cosmetic and Reconstructive Surgery
Related Codes
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