DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Removal of Implantable Devices

Defines medical necessity criteria and prior authorization requirements for removal (and for combined removal with reinsertion/replacement/revision) of surgically implanted devices for Medicare Advantage Plans and Commercial Products under Blue Cross Blue Shield - Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRemoval of Implantable Devices

Policy CodePolicy N/A

Change Typeclarified

Effective Date07/01/2026

Next Review Date

Key ActionPrior authorization is required for Medicare Advantage Plans and recommended for Commercial Products and is obtained via the online tool for participating providers.

POLICY UPDATE CHANGES

Policy documents criteria and prior authorization requirement for removal of surgically implanted devices.

2Primary removal indications required when initial insertion not necessary

1Prior authorization required for MA plans

Coverage Summary

Coverage stance: covered with criteria. Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products. Policy status: DRAFT (effective date 07/01/2026; last updated 01/07/2026).

Medical Necessity Criteria

Removal Only

Removal Only of a surgically implanted device is considered medically necessary when:

Either

If insertion was NOT medically necessary
- Insertion NOT medically necessary: the insertion of the device was determined to be NOT medically necessary
- AND one of the following indications is present
  - complication
  - infection
Insertion medically necessary: the insertion of the device was determined to be medically necessary

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Removal with Reinsertion / Replacement / Revision

When CPT code represents removal AND/OR reinsertion, replacement or revision:

ALL of the following

Removal portion: the removal must be reviewed using the above removal criteria
Reinsertion/Replacement/Revision portion: the reinsertion/replacement/revision must be reviewed to determine medical necessity
Note: In most instances, the criteria from the Medical Necessity policy would be used for review of reinsertion/replacement/revision; however, in other instances, a medical policy may exist for the specific device, or the New Technology and Miscellaneous Services policies can be referenced

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Reimplantation

Reimplantation of the device is considered not medically necessary when the initial implantation was determined to be not medically necessary

Provider Actions & Requirements

Prior Authorization

Prior authorization requirement

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products and is obtained via the online tool for participating providers.

Documentation Required

Medical necessity documentation for removal

Providers must document that either the original insertion was medically necessary, or if insertion was not medically necessary, document the presence of a complication or infection to support removal.

Denial Risk

Reimplantation denial condition

Reimplantation may be considered not medically necessary (and therefore denied) if the initial implantation was determined to be not medically necessary.

Background

This policy documents criteria and prior authorization requirements for the removal of surgically implanted devices. Removal only is considered medically necessary when the original insertion was determined to be medically necessary. If the insertion was determined to be not medically necessary, removal may still be considered medically necessary only if there is a complication or infection present.

When a CPT code represents removal AND/OR reinsertion, replacement, or revision of a device, the removal portion must be reviewed using the removal criteria, and the reinsertion/replacement/revision portion must be reviewed separately to determine medical necessity. In most instances, criteria from the Medical Necessity policy are used for reinsertion/replacement/revision; device-specific medical policies or the New Technology and Miscellaneous Services policies may also apply.

Reimplantation of a device is considered not medically necessary when the initial implantation was determined to be not medically necessary.

Coding: specific procedure codes are covered when the applicable medical criteria are met (codes listed in the attached grid). Benefits may vary by contract; see the appropriate Benefit Booklet or Evidence of Coverage for applicable surgery benefits.

Related policies include device- and procedure-specific policies (for example, Bariatric Surgery; Spinal Cord Stimulation; Implantable Bone Conduction and Bone Anchored Hearing Aids), Coverage of Complications Following a Non-Covered Service, and Prior Authorization policies. Prior authorization is obtained via the online tool for participating providers.

Revision History

2026-07-01effective_date

Draft effective date present: Policy documents criteria and prior authorization requirement for removal of surgically implanted devices.

2026-01-07last_reviewLatest

Policy last updated: Draft indicates criteria and prior authorization requirement for removal of surgically implanted devices; no explicit clinical changes described (non-material).

2026-01-07content_changeLatest

Clarification: Policy documents criteria and prior authorization requirement for removal of surgically implanted devices (no material clinical changes).