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    v1.0.30
    OpenPayerPolicy UpdatesGeneral SurgeryBCBS RI Implant Removal Prior Auth | OpenPayer
    Ask Trek AI about this page
    CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

    Removal of Implantable

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    This policy establishes medical-necessity criteria and authorization requirements for removing surgically implanted devices, including removal with reinsertion, replacement, or revision, for Medicare Advantage plans and commercial products.

    Policy Summary
    PayerBlue Cross Blue Shield - Rhode Island
    PolicyRemoval of Implantable
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2026
    Last ReviewJun 3, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization through the online tool for Medicare Advantage plans; authorization is recommended for Commercial products.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Product lines addressed
    RequiredMedicare Advantage prior authorization
    RecommendedCommercial prior authorization
    2Removal-only coverage pathways
    Not medically necessary

    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.

    Reimplantation after non-medically necessary implantation

    Medical Necessity Criteria

    Removal Only

    Removal only of a surgically implanted device is considered medically necessary when either of the following pathways is met:

    Removal-only coverage pathways

    • Medically necessary initial insertion: The insertion of the device was determined to be medically necessary.

    • Non-medically-necessary initial insertion with qualifying indication

      • The insertion of the device was determined to be not medically necessary.

      • Qualifying indication

        • A complication is present.
        • An infection is present.

    Removal With Reinsertion, Replacement, or Revision

    For CPT codes representing removal and/or reinsertion, replacement, or revision, each component must be reviewed separately for medical necessity.

    Combined removal and device intervention

    • Removal component: The removal must be reviewed using the removal criteria in this policy.
    • Reinsertion, replacement, or revision component: The reinsertion, replacement, or revision must be reviewed to determine medical necessity.

      In most instances, the Medical Necessity policy criteria are used for the intervention component. A device-specific medical policy or the New Technology and Miscellaneous Services policies may apply in other instances.

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

    Authorization and Review Requirements

    Prior Authorization

    Obtain authorization by product

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

    Denial Risk

    Support removal with a qualifying indication

    Removal only is not medically necessary when the initial device insertion was not medically necessary unless a complication or infection is present.

    • Document the qualifying complication or infection when applicable.
    Denial Risk
    Policy Summary
    PayerBlue Cross Blue Shield - Rhode Island
    PolicyRemoval of Implantable
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2026
    Last ReviewJun 3, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization through the online tool for Medicare Advantage plans; authorization is recommended for Commercial products.
    SourceLink
    On This Page
    Medical Necessity CriteriaAuthorization and Review Requirements

    Reimplantation may be denied

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

    Denial Risk

    Submit each procedure component for review

    When a procedure includes removal and reinsertion, replacement, or revision, each component must satisfy a separate medical-necessity review.

    • The removal must be reviewed using the removal criteria.
    • The reinsertion, replacement, or revision must be reviewed to determine medical necessity.