Removal of Implantable Devices
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria for Removal of Implantable Devices
inv-01: Removal Only
Removal Only is considered medically necessary when ONE of the following is met:
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.
Coding and Billing
| No codes listed |
Provider Actions and 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
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)
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: 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
Background
This policy defines medical necessity and prior authorization requirements for the removal of surgically implanted devices for Medicare Advantage and Commercial products. It clarifies that removal procedures may be covered when medical criteria are met, and it explicitly states that reimplantation is not covered when the initial implantation was determined to be not medically necessary.
Definitions
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