CurrentBlue Cross Blue Shield - WisconsinPolicy C-14001

Implants - Facility reimbursement

Governance of facility reimbursement for implants billed on UB-04 forms under Blue Cross Blue Shield - Wisconsin commercial plans; defines which items qualify as implants and billing expectations for providers.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyImplants - Facility reimbursement

Policy CodePolicy C-14001

Change TypeDefinitions and administrative updates

Effective DateMar 12, 2025

Next Review DateN/A

Key ActionEnsure services meet authorization and medical necessity guidelines and follow proper billing and submission using standard codes.

SourceLink

POLICY UPDATE CHANGES

Updated language to include special equipment, attachments, reusable, or disposable kits used in surgery.

Updated definition to include human or non-human tissue.

Removed Connecticut exemption and other market-specific exemption language in prior revisions.

1-3document length

Yesdefinition provided

Nonepolicy exemptions

2cross-references

Facility Coverage Criteria for Implants

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyImplants - Facility reimbursement

Policy CodePolicy C-14001

Change TypeDefinitions and administrative updates

Effective DateMar 12, 2025

Next Review DateN/A

Key ActionEnsure services meet authorization and medical necessity guidelines and follow proper billing and submission using standard codes.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria for implants

Facility reimbursement stance for implants billed on UB-04:

ALL of the following

Implant placement
- The item is implanted in the member (not supplied separate from the member).
The implant is not deemed contaminated or considered waste when submitted on a UB-04.
The implant remains in the member's body upon discharge from the inpatient stay or outpatient procedure.

ALL of the following

Staples, sutures, clips.
Temporary drains, tubes, and similar temporary medical devices.
Instruments, special equipment, attachments, reusable or disposable kits used in surgery that are designed to be removed or discarded during the same operative session.

ALL of the following

There are no exemptions to this policy (no market or provider exemptions).
Exceptions to deny reimbursement only apply if provider, state, or federal contracts and/or mandates indicate otherwise.

Coding Expectations

Coding expectationsmixed

Use industry standard CPT, HCPCS, and revenue codes; standard correct coding applies.

Note

Authorization, medical necessity, and billing compliance

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence; follow proper billing and submission guidelines using industry-standard CPT, HCPCS, and revenue codes, and ensure services are fully supported in the medical record and/or office notes.

Obtain any required prior authorization when applicable per the member’s benefit plan and state regulations.
Use industry-standard, compliant CPT, HCPCS, and/or revenue codes on all claim submissions and ensure documentation supports billed codes.
Follow provider, state, federal, or CMS mandates that may supersede this policy.

Key Definitions

inv-04: Implants

DefinitionObjects or materials implanted such as a piece of tissue (human or non-human), a tooth, a pellet of medicine, a medical device, a tube, a graft, or an insert placed into a surgically or naturally formed cavity to continuously assist, restore or replace function throughout its useful life.

ExamplesStents; artificial joints; shunts; pins; plates; screws; anchors; radioactive seeds; non‑soluble or solid plastic materials used to augment tissues or fill areas removed surgically or traumatically.

Reimbursement conditionImplants must remain in the member's body upon discharge from the inpatient stay or outpatient procedure to be considered for reimbursement.

Exclusions within definitionStaples, sutures, clips, temporary drains, tubes, and similar temporary medical devices are not considered implants.

Policy caveatNo reimbursement when implants are not implanted in the member or are deemed contaminated/considered waste when submitted on a UB‑04, unless provider, state, or federal contracts/mandates indicate otherwise.

inv-05: Non-implants / excluded surgical items

DefinitionInstruments, special equipment, attachments, reusable, or disposable kits used in surgery that are designed to be removed or discarded during the same operative session are not considered implants.

ScopeIncludes surgical instruments and special equipment placed during a procedure but removed prior to or during the same operative session.

Reusable vs disposableBoth reusable and disposable kits/attachments used during surgery that are removed or discarded are excluded from implant reimbursement.

Temporary devicesTemporary drains, tubes, staples, sutures, clips and similar temporary medical devices are specifically excluded from being classified as implants.