DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Removal of Implantable Devices

Customize your policy alerts

Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts

Know when Blue Cross Blue Shield - Rhode Island releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines medical necessity and prior authorization requirements for removal (and when applicable reinsertion/replacement/revision) of surgically implanted devices for Medicare Advantage and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRemoval of Implantable Devices

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization via the online tool for participating providers for Medicare Advantage Plans; recommended for Commercial Products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Prior auth requiredMedicare Advantage Plans

Prior auth recommendedCommercial Products

Not medically necessaryReimplantation

Coverage contingentRemoval criteria

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.

DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Removal of Implantable Devices

Customize your policy alerts

Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts

Know when Blue Cross Blue Shield - Rhode Island releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRemoval of Implantable Devices

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization via the online tool for participating providers for Medicare Advantage Plans; recommended for Commercial Products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Prior auth requiredMedicare Advantage Plans

Prior auth recommendedCommercial Products

Not medically necessaryReimplantation

Coverage contingentRemoval criteria

inv-01: Removal Only

Removal Only is considered medically necessary when ONE of the following is met:

Removal Only medical necessity: Pathway A: Insertion of the device was determined to be medically necessary.

Removal Only medical necessity

complication
infection

inv-02: Removal and Reinsertion/Replacement/Revision — criteria for when removal plus reinsertion/replacement/revision is reviewed

Removal plus reinsertion/replacement/revision:

Removal and reinsertion/replacement/revision review

Removal component: Removal must meet the Removal Only criteria.
Reinsertion/replacement/revision component: Reinsertion, replacement, or revision must be reviewed and meet applicable medical necessity criteria (use device-specific medical necessity policy, Medical Necessity policy, or New Technology and Miscellaneous Services policies as appropriate).

Reimplantation of a surgically implanted device is considered not medically necessary when the documentation shows that the initial implantation was determined to be not medically necessary. Claims for reimplantation in this situation are therefore subject to denial.

Reimplantation is considered not medically necessary when the initial implantation was determined to be not medically necessary. Providers should expect that requests for reimplantation under these circumstances will not meet coverage criteria.

Provider Actions and Prior Authorization

Prior Authorization

Prior authorization required (Medicare Advantage); recommended for Commercial

Prior authorization must be obtained before services for Medicare Advantage members; it is required for Medicare Advantage Plans and recommended for Commercial Products. Participating providers must use the payer’s online prior authorization tool to submit requests.

Required for Medicare Advantage Plans
Recommended for Commercial Products
Obtained via the online tool for participating providers

Step Therapy

Review removal and reinsertion/replacement/revision separately

When CPT coding indicates removal plus reinsertion, replacement, or revision, review each component separately: the removal component is evaluated under the Removal Only criteria, and the reinsertion/replacement/revision component must be reviewed against applicable medical necessity criteria.

Removal component reviewed using Removal Only criteria
Reinsertion/replacement/revision reviewed separately for medical necessity (may reference device-specific policy or Medical Necessity/New Technology policies)

Documentation Required

How to obtain prior authorization (participating providers)

Participating providers must submit prior authorization requests using the insurer’s online tool; see Related Policies section for additional guidance on required documentation and routing.

Use the online prior authorization tool for participating providers
Refer to Related Policies for supplemental documentation requirements

Denial Risk

Denial risk: reimplantation following non‑covered initial implantation

Reimplantation will be considered not medically necessary if the initial implantation was determined to be not medically necessary; claims for reimplantation in that context are at risk of denial and should be supported by documentation demonstrating medical necessity of the original implantation or intervening complications justifying reimplantation.

Reimplantation considered not medically necessary when initial implantation was not medically necessary
Risk of denial for reimplantation claims if initial implantation lacked medical necessity

Definitions

Removal Only — definition and medical necessity criteria

DefinitionRemoval Only: taking out an implanted device without reinsertion, replacement, or revision.

When considered medically necessaryWhen the insertion of the device was determined to be medically necessary.

Alternate medically necessary pathwayWhen the insertion was determined to be NOT medically necessary, but removal is required due to a complication.

Infection pathwayWhen the insertion was determined to be NOT medically necessary, but removal is required due to infection.

Removal plus reinsertion/replacement/revision — definition and review process

DefinitionRemoval with reinsertion/replacement/revision: cases where CPT coding represents both removal and reinsertion, replacement, or revision of a device; each component is reviewed separately.

Review of removal componentThe removal component must be reviewed using the Removal Only criteria.

Review of reinsertion/replacement/revision componentThe reinsertion, replacement, or revision component must be reviewed separately to determine medical necessity (often using the Medical Necessity policy or a device-specific policy).

Reference for additional guidanceWhen no device‑specific policy exists, New Technology and Miscellaneous Services policies may be referenced for reinsertion/replacement/revision decisions.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRemoval of Implantable Devices

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization via the online tool for participating providers for Medicare Advantage Plans; recommended for Commercial Products.

SourceLink

On This Page

OpenPayer

Removal of Implantable Devices

Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts

OpenPayer

Removal of Implantable Devices

Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts

Coverage Criteria for Removal of Implantable Devices

Coding and Billing

Provider Actions and Prior Authorization

Background

Definitions