Prior approval required

Prior Plan approval is required from the Medical Director for therapeutic reconstructive surgery; obtain prior approval before proceeding with reconstructive procedures intended to improve function.

Auth required for listed codes

Certain CPT/HCPCS codes listed as generally not medically necessary require authorization if seeking an exception to coverage; submit an authorization request for those codes marked with an asterisk.

Prior authorization for listed CPT/HCPCS codes

Confirm prior authorization applicability for the excision/lipectomy and suction-assisted lipectomy codes listed (e.g., 15834–15839, 15847, 15876) and reference Policy 91631 for covered indications where required.

Prior authorization for listed lipectomy codes

Providers should obtain prior authorization when required for the enumerated lipectomy and lipectomy-related CPT codes (15836–15839, 15847, 15876–15879) and ensure the clinical indication matches any cross-referenced policy.

Prior auth cross-reference to Policy 91631

Suction-assisted lipectomy codes 15878 and 15879 are noted as covered only for indications in Policy 91631; follow Policy 91631 for prior authorization and coverage determination for these codes.

Codes to reference for prior authorization

When requesting prior authorization for suction-assisted lipectomy and related procedures, reference the exact CPT/HCPCS codes listed in this policy section.

• Examples to reference: 15847, 15876–15879, 17340, 17360, 17380

Procedure codes and policy linkage

This section lists CPT/HCPCS procedure codes referenced by the policy; note that some codes are annotated with 'policy 91631 only' and require cross-policy review when seeking authorization.

Prior authorization: suction assisted lipectomy

Suction-assisted lipectomy codes 15877–15879 are annotated with 'policy 91631 only', indicating prior authorization and review requirements are governed by Policy 91631 for those codes.

• Codes annotated: 15877, 15878, 15879

Prior authorization for craniofacial/forehead reconstruction

Complex craniofacial and forehead reconstruction procedures mapped to CPT codes in the 21150–21181 series typically require prior authorization; verify authorization prior to service.

• Representative codes: 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21181

CPT codes listed in this section

Include the CPT codes listed in the policy's CPT/HCPCS Codes section when determining prior authorization needs; these codes should be referenced on authorization requests.

Codes listed in this segment

The listed CPT codes in the forehead/cranium reconstruction segments are presented as code mappings; prior authorization applicability is not explicitly specified in these chunks but codes should be used for routing/authorization inquiries.

CPT codes listed

This excerpt lists CPT codes relevant to reconstruction that may be subject to coverage rules; no explicit prior authorization rules are stated here—confirm with medical director or payer authorization processes.

Codes to reference for prior authorization

Use the CPT/HCPCS codes presented in the policy when requesting prior authorization and for billing; the list is intended to guide authorization and claims submissions for reconstructive procedures.

Use listed CPT/HCPCS codes for authorization

Providers must use the listed CPT/HCPCS codes corresponding to reconstruction and autograft procedures (including area-based graft codes) when requesting authorization or submitting claims.

• Example autograft codes: 21230, 21235
• Area-based reconstruction codes: 21181–21184

Listed procedure codes — check prior authorization

Verify prior authorization/coverage for the CPT/HCPCS procedure codes listed in this policy section (extensive list across lipectomy, craniofacial reconstruction, grafting, and dermatologic procedures) before performing services.

• Examples: 21182–21184, 21230, 21235, 21244, 21256, 21260, 21261, 21263, 21267, 21268, 21270, 21275, 21280, 21282, 21295, 21296, 26590, 30120

Adjunctive therapy positioning

Fractional CO2 laser therapy is positioned as an adjunctive treatment within a multidisciplinary burn scar rehabilitation program; document that laser therapy is part of a comprehensive treatment plan rather than sole therapy.

Step therapy

No step therapy requirements are specified in the policy fragments provided.

Photographic documentation

Submission of photographic documentation is required for procedures with both reconstructive and cosmetic indications and may be required to demonstrate clinical functional impairment, blepharoplasty indications, or scar revision necessity.

• Photographs should document the anatomical site and degree of functional impairment when applicable.

Prior approval requirement

Prior Plan approval from the Medical Director is required for therapeutic reconstructive surgery and for cases where clinical functional impairment is claimed; obtain authorization prior to treatment.

Authorization for exceptions

Authorization is required for exceptions to the CPT/HCPCS codes listed as generally not medically necessary (codes marked with an asterisk); submit documentation and justification when requesting an exception.

Documentation must support site and covered indication

Provider documentation must support the anatomical site and the covered indication per Policy 91631 when billing excision/lipectomy CPT codes (e.g., hip, buttock, arm, forearm/hand, submental, abdomen).

Coding and documentation linkage

Claims should include the appropriate CPT/HCPCS code for the anatomic site and, where applicable, reference the primary procedure when an add-on/list-separately code (e.g., 15847*) is billed.

List separately documentation

When billing codes listed as 'List separately in addition to code for primary procedure' (for example 15847*), document and bill the add-on separately and include supporting operative details.

• Ensure the primary procedure code is also reported when required by the code descriptor.

Procedure documentation and coding

Document the specific procedure performed and include operative details supporting the selected CPT/HCPCS code (examples in the list include 15847, 15876–15879, 17340, 17360, 17380).

Coding and cross-reference note

Use the exact CPT/HCPCS codes listed in the policy on claims and follow any cross-referenced policies (for example, Policy 91631) when those annotations appear next to codes.

supporting operative documentation

When billing reconstructive midface, LeFort, forehead or orbital procedures, include operative documentation supporting the specific reconstruction performed (e.g., LeFort II vs III, need for bone grafts, intra- vs extracranial approach).

This section provides code descriptors

This code section provides descriptors including graft area thresholds (<40 sq. cm, 40–80 sq. cm, >80 sq. cm) and example indications (e.g., benign cranial bone tumor such as fibrous dysplasia); document graft type and total area when relevant.

• Document total area of bone grafting (<40, 40–80, >80 sq. cm) when billing area-based reconstruction codes.

Document ICD-10 diagnosis to support procedure

Medical records should support the listed ICD-10 diagnoses when submitting claims for blepharoptosis and brow ptosis repair; include the applicable diagnosis code(s) from the policy's diagnosis list.

• Examples include H02.40x series for ptosis, H02.83x for dermatochalasis, and trauma/burn codes where appropriate.

Cosmetic procedures not medically necessary

Therapies and procedures intended to change or restore appearance for cosmetic purposes are considered not medically necessary; do not seek authorization for cosmetic-only indications.

Revision surgery denial risk

Revisions of prior surgery performed for aesthetic/cosmetic reasons are not covered unless there were documented surgical complications such as cellulitis, infection, lymphedema, hematoma, or significant skin or flap necrosis.

Coverage exclusions by ICD-10

Use of ICD-10 codes Z41.1, Z41.8, Z41.9, or Z42.8 excludes coverage of any services and may trigger denial when billed to Priority Health.

• Codes explicitly exclude coverage: Z41.1, Z41.8, Z41.9, Z42.8

Scalp cooling reimbursement stance

Scalp cooling devices and products for prevention of chemotherapy-induced alopecia are considered incidental to chemotherapy administration and are not separately reimbursed; claims billed separately may be denied.

Denial risk when indications not supported

Claims for listed excision/lipectomy codes may be denied if submitted without reference to covered indications specified in Policy 91631 for the anatomical sites noted (e.g., leg, hip, buttock, arm, forearm/hand, submental).

Indication linkage to policy 91631

Using upper extremity, forearm/hand, or related lipectomy codes without meeting the indications in Policy 91631 may trigger denial; ensure the indication aligns with Policy 91631 before billing.

Coding cross-reference/packaging risk

Claims may be denied or require additional review if CPT codes are billed without observing cross-references (for example, 15878/15879 are tied to Policy 91631) or if add-on/list-separate procedures (15847*) are not submitted appropriately.

Coding mismatch/unsupported code risk

Claims may be denied if submitted with codes not included in the policy's CPT/HCPCS listing or if the coding does not match the listed procedural descriptions; ensure billed codes appear in the policy's code lists and match documented services.

Policy cross-reference for suction assisted lipectomy

Claims for certain suction-assisted lipectomy codes may be routed to Policy 91631 as indicated by repeated 'policy 91631 only' annotations; failure to follow the referenced policy could trigger denial or re-routing.

• Keep in mind: 15877–15879 frequently annotated as 'policy 91631 only'.

coding mismatch risk

Formatting anomalies and repeated list artifacts in the code tables may cause confusion; ensure billed CPT/HCPCS codes exactly match policy-listed codes to avoid coding/claim confusion and potential denial.