Prior authorization required for certain mastectomy/reconstruction procedures

Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial Products for some covered mastectomy and reconstruction procedures; authorization is also required for codes listed on the Prior Authorization via Web-Based Tool for Procedures when applicable.

• Applies to the surgery CPT codes listed in the policy (e.g., 11920-11922, 11971, 19301-19307, 19316-19350, 19357-19396).
• Authorization requirement is program-specific: Medicare Advantage = required; Commercial = recommended unless listed on the web-based tool.

Use web-based prior authorization tool for certain reconstruction/removal codes

Some breast implant removal and breast reconstruction procedure codes must be submitted via the insurer’s prior authorization web-based tool; refer to the related Prior Authorization via Web-Based Tool for Procedures policy for the specific code list.

• If a surgery code appears in that web-based tool list, authorization will be required even for Commercial Products.
• See the related web-based tool policy for the exact procedure codes subject to web-based prior authorization.

Be prepared for medical review of certain surgery codes

Some surgery codes listed in this policy may require medical review to determine whether coverage criteria are met; submitting complete clinical documentation at authorization can reduce the need for additional review.

• Medical review may be triggered for specific surgery codes to confirm statutory coverage conditions.
• Include relevant clinical notes and diagnoses when requesting authorization to support coverage determinations.

Obtain required authorizations to avoid denials

Failure to obtain required prior authorization for Medicare Advantage Plans may result in denial of payment; verify plan type and authorization status before scheduling procedures.

• Medicare Advantage Plans: prior authorization is required for some procedures and lack of authorization could trigger denial.
• Commercial Products: authorization is recommended and may be required if the code is on the web-based tool list.

Nipple/areola tattooing: performer and member submission requirements

Tattooing of the nipple/areola (CPT 11920, 11921, 11922) is covered when performed by a physician or a licensed tattoo artist; if a tattoo artist provides the service, the member must complete the special handling form and attach the invoice for processing.

• Permanent makeup artists must be licensed as a tattoo artist in the state where services are rendered.
• When provided by a tattoo artist, the member completes the insurer’s special handling form and mails it with the invoice for reimbursement processing.

Provide written notice of mastectomy/reconstruction coverage to enrollees

Plans must deliver written notice of the availability of mastectomy and reconstruction coverage to participants upon enrollment and annually; issuers must include notice prominently in literature and in the next mass mailing or informational packet.

• Notice must be in writing and prominently positioned in any literature or correspondence distributed by the plan.
• Plans must transmit the notice as part of the yearly informational packet or in the next mass mailing to enrollees.

Submit complete clinical documentation for medical review when requested

Some surgery codes may require medical review and documentation to determine if statutory coverage requirements are met; providers should submit complete clinical records and justification when requested to avoid payment delays.

• Medical review may be required to confirm coverage under R.I. statutes.
• Ensure documentation supports reconstruction, symmetry, prosthesis, or treatment of physical complications as defined by the statute.

Plans cannot deny eligibility or renewals to avoid mastectomy coverage requirements

A group health plan or carrier may not deny eligibility or renewals solely to avoid compliance with the mastectomy coverage law; providers should be aware that managed-care and medical-necessity reviews are permitted but discriminatory plan practices are prohibited.

• Plans may conduct managed-care and medical-necessity reviews, but may not terminate eligibility or renewals to evade statutory requirements.
• Plans may not penalize or reduce reimbursement to attending providers for ordering care consistent with the statute.