CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Removal of Implantable Devices

Defines medical necessity criteria and prior authorization requirements for surgical removal (and related reinsertion/replacement/revision) of implanted medical 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 DateMar 1, 2026

Next Review DateN/A

Key ActionPrior authorization must be obtained via the online tool for participating providers for Medicare Advantage plans and is recommended for Commercial products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MA & Commercialplans addressed

Prior auth requiredMA plans

Prior auth recommendedCommercial

Infection/Complicationexplicit indications

Coverage and Medical Necessity Criteria

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Removal considered medically necessary if insertion was medically necessary: Removal Only of a surgically implanted device is considered medically necessary when the insertion of the device was determined to be medically necessary.

Removal considered medically necessary when initial insertion was not medically necessary but specific indications present: Removal Only is considered medically necessary when the insertion of the device was determined to be NOT medically necessary, AND one of the following indications is present: complication OR infection.

inv-02: Removal and Reinsertion, Replacement or Revision — When CPT codes denote removal with reinsertion/replacement/revision

When CPT codes denote removal with reinsertion/replacement/revision:

Dual review requirement: When the appropriate CPT code represents removal AND/OR reinsertion, replacement, or revision, the removal portion must be reviewed using the Removal Only criteria, AND the reinsertion/replacement/revision portion must be reviewed separately to determine medical necessity (use the Medical Necessity policy or device‑specific policy as applicable).

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products. Participating providers must obtain prior authorization via the online tool. See the Related Policies section for additional guidance.

Applies to Medicare Advantage Plans (required) and Commercial Products (recommended)
Obtain via the payer's online prior authorization tool

Billing Rule

Review Combined Procedure Codes

When a CPT code describes removal plus reinsertion, replacement, or revision of a surgically implanted device, both the removal and the reinsertion/replacement/revision must be reviewed separately to determine medical necessity.

Review removal using the policy's device removal criteria
Review reinsertion/replacement/revision using applicable medical necessity criteria or device-specific policy (or New Technology and Miscellaneous Services policies if applicable)

Documentation Required

Documentation and Denial Risk

Documentation supporting medical necessity must be submitted with the prior authorization request. Reimplantation is not medically necessary when the initial implantation was determined to be not medically necessary.

Include clinical records and rationale that support medical necessity with the PA submission
If initial implant was non-covered/not medically necessary, reimplantation will be denied as not medically necessary

Background and Policy Scope

This policy defines the circumstances under which surgical removal of an implanted device is medically necessary and clarifies related review requirements. It applies to Medicare Advantage and Commercial products; prior authorization is required for Medicare Advantage plans and recommended for Commercial products. When removal procedures also include reinsertion, replacement, or revision (as represented by CPT coding), each component must be reviewed separately to determine medical necessity. For plan-specific coverage details, consult the member’s Benefit Booklet or Evidence of Coverage.

Key Definitions

Removal Only — definition entry

TermRemoval Only

DefinitionRemoval Only of a surgically implanted device is considered medically necessary when the insertion of the device was determined to be medically necessary; or when the insertion was determined to be NOT medically necessary and one of the following indications is present: complication or infection.

Actionable noteIf initial insertion was not medically necessary, document presence of complication or infection to support removal-only coverage.

Removal with reinsertion/replacement/revision — definition entry

TermRemoval with reinsertion/replacement/revision

DefinitionWhen a CPT code represents removal AND/OR reinsertion, replacement or revision of a device: the removal portion must be reviewed using the Removal Only criteria, and the reinsertion/replacement/revision must be reviewed separately to determine medical necessity.

Review guidanceUse the Medical Necessity policy for most reinsertion/replacement/revision reviews; when applicable, reference device‑specific policies or New Technology and Miscellaneous Services policies as noted in Related Policies.