Prior Authorization Required

Prior authorization is required for procedures and associated codes when coverage is requested. Providers must obtain prior authorization before scheduling or performing services listed in the policy and referenced code lists. Failure to obtain prior authorization may result in claim denial or delay.

• Applicable CPT and HCPCS codes listed in the policy (see coding sections)
• Contact Ambetter Nevada prior authorization processes and portals for submission requirements

Cosmetic Procedures Not Covered

Cosmetic procedures performed solely to improve a patient’s normal appearance and self‑esteem are not medically necessary and are generally not a covered benefit. Examples include (but are not limited to) breast augmentation, body contouring, liposuction (except as directed by clinical decision support criteria for lipoma), injectable fillers, tattooing (except post‑mastectomy nipple/areola tattooing), hair transplantation when not to correct disease‑related permanent hair loss, and other services listed under the policy.

Reconstructive Criteria Not Met — Risk of Denial

Requests for reconstructive services must demonstrate that the reconstructive criteria are met. Procedures intended to improve function of an abnormal body part caused by illness, trauma, or congenital defect must document intent and, when applicable, failure of conservative therapy (unless conservative therapy is not standard of care or is contraindicated). Absent documentation of intent, functional impairment, or prior conservative therapy where required, requests risk denial.

Not Medically Necessary Procedures May Be Denied

Procedures expressly listed as not medically necessary in the policy may be denied. Providers should review the policy’s not‑medically‑necessary list prior to submission and consider alternate diagnoses or documentation only when supported by clinical evidence or decision support criteria.

Documentation to Support Medical Necessity

Provide complete medical records to support medical necessity. Documentation should include relevant history, physical exam findings, prior conservative treatments and their outcomes, decision support criteria determinations when applicable, and clear indication of functional impairment or medical necessity. For reconstructive requests, include clinical photographs when applicable to document the condition and the need for reconstruction.

• Medical records showing failure of conservative therapy or rationale if conservative therapy is not appropriate
• Clinical photographs for reconstructive cases when applicable
• Reference decision support criteria documentation when used to justify medical necessity