Removal of Implantable Devices
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Criteria and prior authorization requirements for removal (and related reinsertion/replacement/revision) of surgically implanted devices for Medicare Advantage and Commercial products offered by Blue Cross & Blue Shield of Rhode Island.
No material clinical or coverage changes in this revision.
Coverage Criteria for Removal of Implantable Devices
inv-01: Removal Only
Removal Only of a surgically implanted device is considered medically necessary when:
Primary conditions
- When insertion was medically necessary: Insertion was determined to be medically necessary.
- When insertion was not medically necessary: Insertion was determined to be NOT medically necessary AND (complication OR infection) is present.
inv-02: Removal with Reinsertion/Replacement/Revision
When the appropriate CPT code represents both removal and reinsertion/replacement/revision:
Reimplantation of a surgically implanted device is considered not medically necessary when the initial implantation was determined to be not medically necessary. Such services may be denied under the plan’s coverage determinations.
Consistent with the policy’s coverage stance, any request for device reimplantation will be evaluated against the determination of the original implantation; if the original implantation was not medically necessary, reimplantation is not medically necessary and is not covered.
Code Groups and Attached Grid
| No codes listed |
| No codes listed |
| No codes listed |
Provider Requirements and Billing Guidance
Prior authorization required (Medicare Advantage); recommended for Commercial
Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial Products. Obtain prior authorization via the participating providers' online tool before scheduling services to avoid coverage delays.
Review steps when CPT code includes both removal and reinsertion
When a CPT code represents both removal and reinsertion/replacement/revision, review the removal portion using the Removal Only criteria and review the reinsertion/replacement/revision portion separately to determine medical necessity (typically using the Medical Necessity policy or device-specific/New Technology policies).
- Step 1: Apply the Removal Only criteria to the removal component.
- Step 2: Independently review the reinsertion/replacement/revision component for medical necessity per Medical Necessity or device-specific/New Technology/Miscellaneous Services policies.
Where to obtain prior authorization and coding applicability
Prior authorization is obtained via the participating providers' online tool and applies to Medicare Advantage Plans (required) and Commercial Products (recommended). Coding grids list covered removal codes that are covered when applicable medical criteria are met.
- Use the attached coding grid to identify covered removal codes (covered when medical criteria are met).
- Submit PA requests through the online tool for participating providers.
Denial risk for reimplantation after non‑covered initial implantation
Reimplantation of a device may be denied when the initial implantation was determined to be not medically necessary; reimplantation in that circumstance is considered not medically necessary.
- If documentation shows the initial implantation was not medically necessary, do not expect coverage for subsequent reimplantation; such services may be denied.
Background
This policy defines medical necessity for removal and related procedures for surgically implanted devices. It clarifies that removal alone is considered medically necessary when the original insertion was medically necessary or when an originally non‑medically necessary insertion has since resulted in a complication or infection, while reimplantation is not medically necessary if the initial implantation was not medically necessary. Prior authorization requirements apply for Medicare Advantage and are recommended for Commercial products.
Definitions
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