CurrentAlliance HealthPolicy 1-O-2

Craniofacial Surgery Coverage Criteria

Defines Medicaid coverage, eligibility, and criteria for craniofacial reconstructive procedures for NC Medicaid beneficiaries, including EPSDT considerations for beneficiaries under 21. Affects providers billing NC Medicaid for craniofacial surgery.

Policy Summary

PayerAlliance Health

PolicyCraniofacial Surgery Coverage Criteria

Policy CodePolicy 1-O-2

Change TypeNo material change

Effective DateSep 1, 2024

Next Review DateN/A

Key ActionObtain prior approval and submit required supporting documentation to the DHHS Utilization Review Contractor before rendering craniofacial surgery.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Related clinical coverage policy referenced

3Major sections

21Document chunks

RequiredPrior approval

YesAttachment A present

Coverage & Medical Necessity Criteria

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Covered criteria

Covered when ALL of the following are met

General medical necessity: Procedure, product, or service is individualized, specific, consistent with symptoms or confirmed diagnosis, and not in excess of beneficiary's needs

See 3.1.a

Conservative treatment: Procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide

See 3.1.b

Not for convenience: Procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, caretaker, or provider

See 3.1.c

Specific functional impairment: Injury, disease, birth defect, or growth and development results in functional impairment, obstruction of an orifice, or bodily distortion that limits activities of daily living and the treatment is expected to improve the impairment

See 3.2.1.a

Medical necessity requirement

Covered when ALL of the following are met

Medical necessity vs cosmetic: Procedure is primarily to restore impairment or correct deformity caused by injury, disease, birth defect, or growth and development

If cosmetic only, not covered

Craniofacial surgery performed primarily for cosmetic reasons is not covered. Specifically, Medicaid shall not cover craniofacial procedures when they are performed for cosmetic purposes rather than primarily to restore impairment or correct deformity caused by injury, disease, birth defects, or growth and development in children.

Services that are experimental, investigational, or provided as part of a clinical trial are not covered under this policy. Claims for such procedures are excluded from coverage and are considered not medically necessary for the purposes of Medicaid reimbursement.

Medicaid does not cover procedures that are solely cosmetic in nature. Craniofacial surgery that is performed for cosmetic reasons rather than to restore impairment or correct deformity is explicitly excluded from coverage, including for beneficiaries under Medicaid unless the procedure meets coverage criteria described elsewhere in this policy.

A set of craniofacial procedure codes listed in Attachment A require prior approval and are not eligible for routine automatic payment without authorization. The list in Attachment A (not necessarily exhaustive) includes multiple CPT codes such as 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21159, 21160, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230, 21244, 21245, 21246, 21247, 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21270, 21275, 21295, 21296 among others shown in Attachment A; providers must obtain prior approval for listed codes before rendering services.

Examples of non-covered services include procedures that do not meet Section 2.0 eligibility or Section 3.0 coverage criteria, duplicate services provided by another provider, procedures that are experimental or investigational, and procedures that are cosmetic-only and not primarily intended to restore impairment or correct deformity. Such services are considered not medically necessary and will be denied.

This policy explicitly excludes procedures that are cosmetic-only — defined as interventions performed primarily for appearance rather than to restore function or correct deformity. Cosmetic-only craniofacial surgeries are not covered by Medicaid.

Procedure & Billing Codes

Codes referencedmixed

No explicit CPT/ICD codes listed in this extract

The document excerpt does not enumerate CPT, HCPCS, or ICD-10 codes for craniofacial surgery.

Procedure codes requiring prior approval (Attachment A)CPTCovered

21120	Listed in Attachment A as requiring prior approval
21121	Listed in Attachment A as requiring prior approval
21122	Listed in Attachment A as requiring prior approval
21123	Listed in Attachment A as requiring prior approval
21125	Listed in Attachment A as requiring prior approval
21127	Listed in Attachment A as requiring prior approval
21137	Listed in Attachment A as requiring prior approval
21138	Listed in Attachment A as requiring prior approval
21139	Listed in Attachment A as requiring prior approval
21141	Listed in Attachment A as requiring prior approval

1–10 of 46

1/5

Procedure codes requiring prior approvalCPTCovered

21120	Listed among procedure codes requiring prior approval
21121	Listed among procedure codes requiring prior approval
21122	Listed among procedure codes requiring prior approval
21123	Listed among procedure codes requiring prior approval
21125	Listed among procedure codes requiring prior approval
21127	Listed among procedure codes requiring prior approval
21137	Listed among procedure codes requiring prior approval
21138	Listed among procedure codes requiring prior approval
21139	Listed among procedure codes requiring prior approval
21141	Listed among procedure codes requiring prior approval

1–10 of 46

1/5

Unlisted Procedure or Servicemixed

Unlisted CPT	Follow CPT Codebook instructions for unlisted procedures and submit special report
Unlisted HCPCS	Follow HCPCS instructions for unlisted procedures and submit special report

Coding specificity

RequirementReport ICD-10-CM and PCS to the highest level of specificity that supports medical necessity; use the current ICD-10 edition and subsequent editions in effect at time of service.

Use of code setsUse current CPT, HCPCS, and UB-04 Data Specifications Manual editions for procedure and revenue codes; refer to the applicable edition for code descriptions.

Unlisted proceduresIf no specific CPT/HCPCS code exists, report the service using the appropriate unlisted procedure code and follow CPT/HCPCS instructions (include special report when required).

AccuracyReport the most specific billing code that accurately and completely describes the procedure, product, or service provided.

Prior Authorization, Documentation & Billing Requirements

Prior Authorization

Prior Authorization Required

Prior approval is required before rendering services covered by this policy. Providers must obtain prior approval for the procedures listed in Attachment A and for craniofacial surgery and related reconstructive procedures. Failure to obtain prior approval may result in claim denial.

Prior approval required for beneficiaries of any age, including those under 21 despite EPSDT protections
Prior approval is required for specific CPT/HCPCS procedure codes listed in Attachment A (this list may not be all inclusive)

Note

Eligibility Verification & EPSDT / Prior Approval

Verify Medicaid eligibility at each service encounter. For beneficiaries under age 21, EPSDT protections do not waive the requirement to obtain prior approval when the service requires it. Refer to NCTracks and the NC DHHS EPSDT provider resources for additional guidance.

Verify enrollment and eligibility in NCTracks before rendering services
If beneficiary is under 21, follow EPSDT guidance but still obtain prior approval when required

Documentation Required

Coding Specificity & Unlisted Procedure Documentation

Report the most specific CPT/HCPCS code that accurately and completely describes the service. If no specific code exists, use the appropriate unlisted procedure code and include the required special report and documentation per the current CPT/HCPCS instructions.

Use current CPT, HCPCS, and UB-04 coding manuals in effect at time of service
When reporting an unlisted procedure, include operative notes and a special report per CPT/HCPCS instructions
Include CPT codes describing the procedures with prior approval submission

Documentation Required

Required Prior Approval Documentation

Submit a complete prior approval request and all supporting clinical documentation to the DHHS Utilization Review Contractor. Include details that substantiate medical necessity and expected functional improvement.

Submit the prior approval request and all supporting health records to the DHHS Utilization Review Contractor
Include location and cause of defect, pre-operative photographs, CPT codes for planned procedures, and documentation that treatment is expected to improve the impairment

Denial Risk

Denial Triggers

Claims may be denied if the beneficiary does not meet eligibility (Section 2.0) or coverage criteria (Section 3.0), if the service duplicates another provider's service, or if prior approval was not obtained when required.

Denial risk if eligibility not met (Section 2.0)
Denial risk if policy criteria not met (Section 3.0)
Denial risk for duplicate services or when prior approval is not obtained

Key Definitions

Craniofacial surgery — definition

DefinitionCraniofacial surgery encompasses reconstructive procedures of the cranium and face to correct deformities from birth defects, trauma, or disease and to restore form and function.

Coverage conditionCovered when a resulting functional impairment, obstruction of an orifice, or bodily distortion limits activities of daily living and treatment is expected to improve the impairment.

Goals of surgeryObjectives include correcting deformities of the face and skull and restoring craniofacial form and function by medical and surgical means.

ScopeIncludes procedures to correct deformities caused by birth defects, trauma, disease, or growth and development.

EPSDT (Early and Periodic Screening, Diagnostic, and Treatment)

What EPSDT isEarly and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement (42 U.S.C. §1396d(r)) that requires coverage of medically necessary services for beneficiaries under 21 to correct or ameliorate defects, illnesses, or conditions identified by screening or evaluation.

Scope for under-21 beneficiariesEPSDT may require exceeding or waiving policy limitations on scope, amount, duration, frequency, location of service, or other criteria when provider documentation shows the service is medically necessary to correct, improve, or maintain the child’s health.

ExceptionsEPSDT does not require coverage of services that are unsafe, ineffective, experimental/investigational, or not generally recognized as accepted medical practice.

Cosmetic versus reconstructive — Medicaid coverage

Medicaid stanceMedicaid shall not cover craniofacial surgery when performed for cosmetic reasons rather than primarily to restore impairment or correct deformity.

Cosmetic-only exclusion — childrenProcedures performed for cosmetic reasons rather than to correct deformity caused by injury, disease, birth defects, or growth and development are not covered in children.

Relation to medical necessityCoverage requires the procedure be primarily to restore impairment or correct deformity; cosmetic-only procedures are considered not medically necessary.

OpenPayer

Craniofacial Surgery Coverage Criteria

Coverage & Medical Necessity Criteria

Procedure & Billing Codes

Prior Authorization, Documentation & Billing Requirements

Background & Scope

Key Definitions