CurrentAnthemPolicy G-06111

Medical Recalls, Reimbursement Policy

Governs Anthem Medicare Advantage reimbursement for repair, replacement, and related procedures when items are subject to medical recalls; applies to providers submitting claims for Medicare Advantage members in applicable states listed. It outlines when reimbursement is allowed, credit/recoupment rules, and documentation/billing expectations.

Policy Summary

PayerAnthem

PolicyMedical Recalls, Reimbursement Policy

Policy CodePolicy G-06111

Change TypeAdded implantable devicesminor wording clarifications

Effective DateMay 22, 2024

Next Review Date

Key ActionBill the appropriate condition/value/modifier/diagnosis codes to identify a medically recalled item when applicable.

SourceLink

POLICY UPDATE CHANGES

added implantable devices under applicable items

added the words 'or item' to policy language

6applicable recalled item types

states listedMedicare Advantage states named

possiblerecoupment allowed

requireddocumentation required

Medical Recall Coverage Rules

Medical recall coverage rules

Anthem Medicare Advantage reimbursement policy for recalled items and related procedures

Anthem Medicare Advantage does not allow reimbursement for repair or replacement of items due to a medical recall unless provider, state, federal, CMS contracts, and/or requirements indicate otherwise.

Applicable items

Durable medical equipment
Supplies
Prosthetics
Orthotics

Policy Summary

PayerAnthem

PolicyMedical Recalls, Reimbursement Policy

Policy CodePolicy G-06111

Change TypeAdded implantable devicesminor wording clarifications

Effective DateMay 22, 2024

Next Review Date

Key ActionBill the appropriate condition/value/modifier/diagnosis codes to identify a medically recalled item when applicable.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding and Identification of Recalled Items

Recalled item identification codesmixed

Policy instructs use of appropriate condition code, value code, modifier, and/or diagnosis code to identify recalled items; specific codes not listed in policy text.

Coding requirement — Use industry standard codes supported by medical record

Required code systemsUse industry standard CPT, HCPCS, and/or revenue codes on all claim submissions.

Medical record supportBilled codes must be fully supported in the medical record and/or office notes.

Compliance requirementYou are required to use industry standard, compliant codes on all claim submissions; failure may result in claim rejection, denial, recovery, or adjustment.

ApplicabilityUnless otherwise noted, reimbursement policies apply to both participating and non‑participating professional providers and facilities.

Superseding mandatesPolicy may be superseded by provider, state, federal, or CMS mandates; Anthem may recoup payments to the effective date if implementation is delayed.

Billing, Authorization, and Recoupment Expectations

Billing Rule

Billing and authorization expectations

When applicable, providers should bill the appropriate condition code, value code, modifier, and/or diagnosis code to identify a medically recalled item. Use industry-standard, compliant codes on all claim submissions and ensure the medical record supports the billed services.

Bill with correct CPT, HCPCS, revenue, and/or ICD-10 codes that reflect the recalled item and related procedures.
Include applicable condition codes, value codes, and modifiers to indicate replacement or recall status.
Ensure documentation in the medical record supports medical necessity for removal/replacement procedures.

Prior Authorization

Prior authorization / medical necessity

Anthem will allow reimbursement of medically necessary procedures to remove and replace recalled or replaced devices or items, subject to authorization and medical necessity requirements. Anthem will not reimburse for repair or replacement of items due to a recall unless provider, state, federal, or CMS requirements indicate otherwise. Payment for a replaced device or item will be reduced by the amount of any credit the facility receives for that device or item.

Applicable items include durable medical equipment, supplies, prosthetics, orthotics, drugs/vaccines, and implantable devices.
If an inpatient or outpatient facility receives full or partial credit for a replaced device/item due to recall, Anthem will reduce payment by that credit amount.
Providers must follow prior authorization and medical necessity processes as appropriate for the procedure.

Denial Risk

Recoupment and legal participation

Anthem will participate in and provide documentation for class action lawsuits related to medical recalls. When Anthem has reimbursed providers for repair, replacement, or procedures related to recalled items, Anthem is entitled to recoup or recover fees from the manufacturer, distributor, or the provider if the provider received full or partial credit for the device or item.

Anthem will supply providers with medical recall information for dissemination to affected members.
Anthem may recoup payments from manufacturers/distributors for recalled items when appropriate.
If a provider received full or partial credit for a replaced device/item and Anthem reimbursed the provider, Anthem may recover the corresponding amount from the provider.

Reimbursement Definitions

General reimbursement definitions and requirements

PurposeProvides guidance to assist accurate claims submission and outline basis for reimbursement under Anthem Medicare Advantage.

Documentation standardServices must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.

Claims submission expectationFollow proper billing and submission guidelines and use industry standard, compliant codes on all claim submissions.

Consequence of noncomplianceIf appropriate coding/billing guidelines or current reimbursement policies are not followed, Anthem may reject/deny the claim, recover/recoup payment, or adjust reimbursement.

Policy updatesAnthem reserves the right to review and revise policies and will publish the most current policy to the website.