NC Medicaid Craniofacial Surgery
Customize your policy alerts
Sign up for Blue Cross Blue Shield - North Carolina Policy 1-O-2 alerts
Get alerted when Policy 1-O-2 changes without checking for updates manually.
Monitor payer policy activity
Policy governing coverage criteria and requirements for craniofacial surgery services under Blue Cross Blue Shield - North Carolina for Medicaid beneficiaries, including EPSDT provisions for beneficiaries under 21.
Subsection 3.2.1 was clarified and redundant text removed.
Removed the table of CPT codes that no longer require prior approval.
Added 4A, Dental Services to the list of related coverage policies.
Coverage Criteria and Exclusions
Covered Criteria (referenced)
Covered when ALL applicable criteria in sections 3.2.1, 3.2.2 and any Medicaid additional criteria are met; prior approval may be required per Section 5.1 and Attachment A.
Full itemized criteria are in the referenced sections of the policy.
Medical necessity criteria
Covered when ALL of the following are met:
Section 3.1
Section 3.2.1
Not Covered Conditions
Medicaid will not cover the procedure when ANY of the following apply:
Section 4.1
Section 4.2.1
The policy’s Table of Contents identifies a section titled “When the Procedure, Product, or Service Is Not Covered” (Section 4.0) and subsections including “General Criteria Not Covered” and “Specific Criteria Not Covered”. In this excerpt the TOC signals that exclusion rules and scope (Sections 4.0–4.2.2) exist in the full policy but the detailed lists of specific exclusions are contained in those sections rather than in the TOC itself. Refer to Section 4.0 and its subsections for the full exclusion language and applicability to Medicaid and EPSDT beneficiaries.
Craniofacial surgery performed for cosmetic reasons rather than primarily to restore impairment or correct deformity is explicitly excluded. Section 4.2.1 states that Craniofacial surgery performed for cosmetic reasons is not covered when it is not primarily intended to treat impairment or correct deformity in children resulting from injury, disease, birth defects, or growth and development.
The policy excludes procedures that are experimental, investigational, or part of a clinical trial. Section 4.1.d lists these categories among the conditions under which Medicaid shall not cover the procedure, product, or service.
For children, the policy reiterates that craniofacial surgery performed for cosmetic reasons rather than to restore impairment or correct deformity is not covered under Medicaid (Section 4.2.1). Additionally, Section 4.1 clarifies general non‑coverage reasons that apply across populations, including lack of eligibility, failure to meet coverage criteria, duplication of another provider’s service, and treatments that are experimental, investigational, or part of clinical trials.
The policy identifies duplication and trial/experimental status as exclusion triggers: Medicaid will not cover a procedure that duplicates another provider’s procedure, product, or service (Section 4.1.c). Procedures that are experimental, investigational, or part of a clinical trial are also excluded (Section 4.1.d). The Table of Contents and Section 4.0 emphasize that services not meeting Sections 2.0/3.0 eligibility or coverage criteria, duplicate services, cosmetic-only procedures, or investigational treatments are considered not medically necessary and therefore not covered.
Coding and Billing Codes
| not listed | Policy directs providers to use current CPT, HCPCS, ICD-10-CM/PCS codes at highest specificity; code lists are not documented within the policy text. |
| 21120 | CPT code listed in prior approval list |
| 21121 | CPT code listed in prior approval list |
| 21122 | CPT code listed in prior approval list |
| 21123 | CPT code listed in prior approval list |
| 21125 | CPT code listed in prior approval list |
| 21127 | CPT code listed in prior approval list |
| 21137 | CPT code listed in prior approval list |
| 21138 | CPT code listed in prior approval list |
| 21139 | CPT code listed in prior approval list |
| 21141 | CPT code listed in prior approval list |
| unlisted CPT | Use CPT unlisted procedure code with special report per CPT instructions |
| unlisted HCPCS | Use HCPCS unlisted procedure code with special report per HCPCS instructions |
Prior Authorization, Documentation, and Provider Requirements
Prior Approval referenced in TOC — details in sections 5.1–5.2/Attachment A
Table of Contents indicates Prior Approval is a required section (5.1) and Prior Approval Requirements (5.2); specific prior authorization rules and affected codes are detailed in those sections and Attachment A elsewhere in the policy.
- Prior Approval is listed in the Table of Contents as section 5.1.
- Prior Approval Requirements are listed as section 5.2 (with subsections 5.2.1 General and 5.2.2 Specific).
- Attachment A (Claims-Related Information) contains procedure codes that may require prior approval.
Provider must request prior approval per sections 5.1–5.2
The policy requires providers to request prior approval per the Prior Approval (5.1) and Prior Approval Requirements (5.2) sections; providers must follow submission instructions in those sections when requesting authorization.
- Submit prior approval requests to the DHHS Utilization Review Contractor as specified in 5.2.
- Include all health records and any other records that support the beneficiary has met the specific criteria in Subsection 3.2.
Prior approval is required — obtain before service
Prior approval is required for craniofacial surgery — providers must obtain prior approval before performing the procedure and follow the Prior Approval Requirements in section 5.2.
- Medicaid shall require prior approval for Craniofacial Surgery; obtain prior approval before rendering the procedure.
- Refer to Attachment A for procedure codes that require prior approval.
Obtain prior approval when specified; EPSDT does not waive authorization
If a service in this policy requires prior approval, the provider must obtain it; the EPSDT provision for beneficiaries under 21 does not eliminate prior approval requirements.
- EPSDT does not waive the requirement for prior approval when the service requires it.
- Providers should reference NCTracks guidance and EPSDT provider resources for additional prior approval information.
Submit prior approval request and supporting records to DHHS Utilization Review Contractor
Prior approval is required before performing craniofacial surgery; submit the prior approval request and all supporting health records to the DHHS Utilization Review Contractor as described in Prior Approval Requirements.
- Submit the prior approval request and all health records that support meeting Subsection 3.2 criteria to the DHHS Utilization Review Contractor.
- Prior approval is required for most procedures or related components of reconstruction.
Certain CPT codes require prior approval (see Attachment A)
Select craniofacial procedure CPT codes listed in Attachment A require prior approval; providers must check Attachment A for the specific CPT codes that require authorization.
- Attachment A includes a list of procedure codes requiring prior approval (examples shown in Attachment A).
- Providers must refer to Attachment A for the full prior approval code list.
Required documentation to support prior approval requests
Prior approval requests must include the defect location and cause, pre-operative photographs, CPT codes for planned procedures, and supporting documentation that treatment is reasonably expected to improve the impairment.
- Location and cause of the defect.
- Pre-operative photographs.
- CPT codes describing procedures to be performed.
- Documentation that treatment can reasonably be expected to improve the impairment.
Unlisted procedure coding and documentation requirements
When reporting procedures with no specific CPT/HCPCS code, comply with CPT/HCPCS instructions for unlisted procedures and submit the required special report or documentation per the current codebook editions.
- Follow the Instructions for Use of the CPT Codebook for unlisted procedure codes and special reports.
- Follow HCPCS instructions for unlisted procedure codes and special reports when applicable.
Verify Medicaid eligibility and document EPSDT justification for <21
Providers must verify each Medicaid beneficiary's eligibility at every service and, for beneficiaries under 21, document how the requested services meet EPSDT medical necessity criteria.
- Verify Medicaid eligibility each time a service is rendered.
- For beneficiaries under 21, document how the requested service corrects or ameliorates a defect or condition under EPSDT.
Coverage denial triggers — eligibility, criteria, duplication, experimental procedures
Claims will be denied when the beneficiary does not meet eligibility requirements (Section 2.0), does not meet coverage criteria (Section 3.0), duplicates another provider's service, or the procedure is experimental/investigational or part of a clinical trial.
- Non‑eligible beneficiary or not meeting Section 2.0 eligibility.
- Does not meet coverage criteria in Section 3.0.
- Service duplicates another provider's procedure.
- Procedure is experimental, investigational, or part of a clinical trial.
Denial risk from nonspecific coding or missing prior approval
Failure to use ICD-10-CM/PCS to the highest level of specificity, to use current CPT/HCPCS/UB-04 specifications, or to obtain required prior approval for listed procedure codes may result in claim denials.
- Report ICD-10-CM and PCS to the highest level of specificity that supports medical necessity.
- Use the current CPT, HCPCS, and UB-04 specifications in effect at the time of service.
- Obtain prior approval for procedure codes listed in Attachment A when required.
Background and Scope
This excerpt of the policy is limited to the title page and a detailed Table of Contents that enumerates sections such as Description of the Procedure, Eligibility, Coverage (general and specific), When Not Covered, Requirements and Limitations (including Prior Approval), and provider‑related sections. No clinical background or condition descriptions are provided in this portion of the document.
Key Definitions
Policy Revision History and Changes
Subsection 3.2.1 was revised: clarified conditions and redundant text removed.
Prior-approval related text (previously in Attachment A, Letter C) was moved into Subsection 5.1.
Removed the table of CPT codes that no longer require prior approval from Attachment A.
The policy record indicates both material and non‑material edits were made. Notably, prior‑approval‑related text was moved from Attachment A into Subsection 5.1 and a non‑inclusive example list was removed; Attachment A edits also changed prior approval code listings. Effective and review dates are not present in the excerpt.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.