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Medical Policy Reference List (Commercial)2022 Benefit Procedure Code ListUpdated January 2022EXCEPT AS OTHERWISE NOTED IN THE DATE COLUMN, THESE CODES ARE EFFECTIVE ON OR BEFORE JANUARY 1, 2022.Our medical policy impacts all our coverage decisions. This list includes Current Procedural Terminology (CPT ) and/or Healthcare Common Procedure Coding System (HCPCS) codes that, based on our medical policy, are:- Subject to a medical necessity review,- Candidates for a predetermination,- Not a benefit for our members,- Considered experimental, investigational and unproven (EIU), or- Not on our prior authorization list (with some exceptions based on members’ benefit plans)This is not an exhaustive list of all codes. Codes may change, and this list may be updated throughout the year. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Membercontracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply.For information on how to submit a voluntary predetermination request, refer to our Utilization Management section on our website at https://www.bcbsil.com/provider/claims/um.html. Predetermination requests may be submittedvia the Availity Provider Portal (availity.com) using the Availity Attachments tool.This information is not applicable to services provided to any of our HMO or government programs members.Procedure Code GroupsProcedure Code Group DescriptionProcedures/services reviewed against Medical Policy Criteria. Submit for predetermination to avoid post-service review.Medical Policy Criteria (MP Criteria)Highlighted procedures/services in this code group may require Prior Authorization per contract agreement.Non CoveredProcedures/services not covered by the Plan. Not subject to pre-service review.Experimental, Investigational,Unproven (EIU)Procedures/services not reimbursed by the Plan. Not subject to pre-service review. Check EIU policy CPCP028, which is one of our Clinical Payment and Coding Policy (CPCP).Unlisted or UndefinedProcedures/services not specifically defined or classified, maybe subject to contract/clinical review.PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.Note: Some codes will appear twice if Ending Date and Effective Date are within the same quarter period. (codes in RED text)CodeCode Description00640Anesth Spine Manipulation00797Anesth Surgery For Obesity07957Weight Loss11920Correct Skin Color 6.0 Cm/ 11921Correct Skn Color 6.1-20.0Cm11922Correct Skin Color Ea 20.0CmCode Group & DescriptionMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.Non Covered: Procedure/service not covered by the Plan. Not subject to pre-servicereview.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.Medical Policy No.Medical Policy TitleEffective DateEnding DateTHE803.016Manipulation Under AnesthesiaSUR716.003Bariatric etic and Reconstructive ProceduresReconstructive and Contralateral MammaplastyCosmetic and Reconstructive ProceduresReconstructive and Contralateral MammaplastyCosmetic and Reconstructive ProceduresReconstructive and Contralateral MammaplastyCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSleep Related Breathing Disorders: Surgical ManagementCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSleep Related Breathing Disorders: Surgical ManagementCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSleep Related Breathing Disorders: Surgical ManagementCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSleep Related Breathing Disorders: Surgical ManagementTx Contour Defects 1 Cc/ MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.Tx Contour Defects 1.1-5.0CcMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.Tx Contour Defects 5.1-10CcMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.11954Tx Contour Defects 10.0 CcMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.11960Insert Tissue Expander(S)MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.SUR716.001Cosmetic and Reconstructive Procedures11970Rplcmt Tiss Xpndr Perm ImpltMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.SUR716.009SUR716.001SUR716.011Breast Implant, Removal and/or InsertionCosmetic and Reconstructive ProceduresReconstructive Breast Surgery11980Implant Hormone Pellet(S)MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service nded Drug ProductsGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesHormone Replacement Therapies (HRT) Using Implanted Pellets for Women and Delayed PubertyTestosterone Replacement Therapies11981Insert Drug Implant DeviceMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.SUR717.001RX501.007RX501.076RX501.082Gender Assignment Surgery and Gender Reassignment Surgery with Related ServicesHormone Replacement Therapies (HRT) Using Implanted Pellets for Women and Delayed PubertyTestosterone Replacement TherapiesTreatment of Opioid Dependence11983Remove/Insert Drug ImplantMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.SUR717.001RX501.007RX501.076RX501.082Gender Assignment Surgery and Gender Reassignment Surgery with Related ServicesHormone Replacement Therapies (HRT) Using Implanted Pellets for Women and Delayed PubertyTestosterone Replacement TherapiesTreatment of Opioid Dependence15734Muscle-Skin Graft TrunkSUR716.011Reconstructive and Contralateral Mammaplasty15758Free Fascial Flap MicrovascSUR701.024Surgery for Lipedema and Lymphedema15769Grfg Autol Soft Tiss Dir ExcSUR716.021SUR716.011Adipose-Derived Stem Cells in Autologous Fat Grafting to the BreastReconstructive Breast Surgery1/15/2021119501195111952Updated January 2022MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.2022 Commercial Procedure Code List BCBSIL1/47
15771Grfg Autol Fat Lipo 50 Cc/ 15772Grfg Autol Fat Lipo Ea Addl15775Hair Trnspl 1-15 Punch Grfts15776Hair Trnspl 15 Punch GraftsMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15780Dermabrasion Total FaceMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15781Dermabrasion Segmental FaceMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15782Dermabrasion Other Than FaceMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15783Dermabrasion Suprfl Any SiteMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15786Abrasion Lesion SingleMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15787Abrasion Lesions Add-OnMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15788Chemical Peel Face EpidermMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15789Chemical Peel Face DermalMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15792Chemical Peel NonfacialMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15793Chemical Peel NonfacialMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15820Revision Of Lower Eyelid15821Revision Of Lower Eyelid15822Revision Of Upper Eyelid15823Revision Of Upper EyelidMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15824Removal Of Forehead WrinklesMP Criteria: Procedure/service reviewed against Medical Policy Criteria, may requirePrior Authorization per contract agreement.15825Removal Of Neck WrinklesMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15826Removal Of Brow WrinklesMP Criteria: Procedure/service reviewed against Medical Policy Criteria, may requirePrior Authorization per contract agreement.15828Removal Of Face Wrinkles15829Removal Of Skin WrinklesMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service pose-Derived Stem Cells in Autologous Fat Grafting to the BreastReconstructive Breast SurgeryAdipose-Derived Stem Cells in Autologous Fat Grafting to the BreastReconstructive Breast SurgerySUR716.0011/15/20211/15/2021Cosmetic and Reconstructive ProceduresSUR716.001Cosmetic and Reconstructive SUR716.001SUR717.001Acne ManagementCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesNonpharmacologic Treatment of RosaceaAcne ManagementCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesNonpharmacologic Treatment of RosaceaAcne ManagementCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesNonpharmacologic Treatment of RosaceaAcne ManagementCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesNonpharmacologic Treatment of RosaceaAcne ManagementCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesAcne ManagementCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesAcne ManagementChemical PeelsGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesNonpharmacologic Treatment of RosaceaAcne ManagementChemical PeelsGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesNonpharmacologic Treatment of RosaceaAcne ManagementChemical PeelsGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesNonpharmacologic Treatment of RosaceaAcne ManagementChemical PeelsGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesNonpharmacologic Treatment of RosaceaBlepharoplasty, Blepharoptosis and Brow RepairGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesBlepharoplasty, Blepharoptosis and Brow RepairGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesBlepharoplasty, Blepharoptosis and Brow RepairGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesBlepharoplasty, Blepharoptosis and Brow RepairGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgical Deactivation of Headache Trigger SitesCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgical Deactivation of Headache Trigger SitesCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSUR716.001Cosmetic and Reconstructive SUR716.001SUR717.001SUR701.024Cosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgery for Lipedema and LymphedemaCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgery for Lipedema and LymphedemaCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgery for Lipedema and LymphedemaCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgery for Lipedema and LymphedemaCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgery for Lipedema and LymphedemaCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgery for Lipedema and LymphedemaCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgery for Lipedema and LymphedemaCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgery for Lipedema and LymphedemaCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgery for Lipedema and LymphedemaSurgical Treatment of GynecomastiaCosmetic and Reconstructive ProceduresSurgery for Lipedema and LymphedemaCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgery for Lipedema and LymphedemaCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgery for Lipedema and LymphedemaCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgery for Lipedema and LymphedemaCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesSurgery for Lipedema and LymphedemaExc Skin AbdMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.Excise Excessive Skin ThighMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.Excise Excessive Skin LegMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.Excise Excessive Skin HipMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.Excise Excessive Skin ButtckMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15836Excise Excessive Skin ArmMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15837Excise Excess Skin Arm/HandMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15838Excise Excess Skin Fat PadMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15839Excise Excess Skin & TissueMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15847Exc Skin Abd Add-OnMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15876Suction Lipectomy Head&NeckMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15877Suction Lipectomy TrunkMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15878Suction Lipectomy Upr ExtremMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.15879Suction Lipectomy Lwr ExtremMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.Removal Of Pressure SoreUnlisted: Procedure/service not specifically defined or classified, maybe subject tocontract/clinical review.17106Destruction Of Skin LesionsMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.THE801.028SUR704.008THE801.030Acne ManagementLaser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and Other External Vascular MalformationsNonpharmacologic Treatment of Rosacea17107Destruction Of Skin LesionsMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.THE801.028SUR704.008THE801.030Acne ManagementLaser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and Other External Vascular MalformationsNonpharmacologic Treatment of Rosacea17108Destruction Of Skin LesionsMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.THE801.028SUR704.008THE801.030Acne ManagementLaser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and Other External Vascular MalformationsNonpharmacologic Treatment of Rosacea17340Cryotherapy Of SkinTHE801.028Acne Management17360Skin Peel TherapyTHE801.028Acne Management158301583215833158341583515999Updated January 2022EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review.Check EIU policy CPCP028, which is one of our Clinical Payment and Coding Policy(CPCP).MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.2022 Commercial Procedure Code List BCBSIL2/47
MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.Unlisted: Procedure/service not specifically defined or classified, maybe subject tocontract/clinical review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.17380Hair Removal By Electrolysis17999Skin Tissue Procedure19105Cryosurg Ablate Fa Each19300Removal Of Breast Tissue19303Mast Simple Complete19316Suspension Of BreastMP Criteria: Procedure/service reviewed against Medical Policy Criteria, may requirePrior Authorization per contract agreement.19318Breast ReductionMP Criteria: Procedure/service reviewed against Medical Policy Criteria, may requirePrior Authorization per contract agreement.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.19325Breast Augmentation W/Implt19328Rmvl Intact Breast Implant19330Rmvl Ruptured Breast Implant19340Insj Breast Implt Sm D MastMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.19342Insj/Rplcmt Brst Implt Sep DMP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.19350Breast Reconstruction19355Correct Inverted Nipple(S)19357Tiss Xpndr Plmt Brst Rcnstj19361Brst Rcnstj Latsms Drsi Flap19364Brst Rcnstj Free Flap19370Revj Peri-Implt Capsule Brst19371Peri-Implt Capslc Brst Compl19499Breast Surgery Procedure20527Inj Dupuytren Cord W/Enzyme20560Ndl Insj W/O Njx 1 Or 2 Musc20561Ndl Insj W/O Njx 3 Musc20979Us Bone Stimulation20982Ablate Bone Tumor(S) Perq20983Ablate Bone Tumor(S) Perq20985Cptr-Asst Dir Ms Px20999Musculoskeletal Surgery21073Mnpj Of Tmj W/Anesth21083Prepare Face/Oral Prosthesis21085Prepare Face/Oral ProsthesisPrepare Face/Oral Prosthesis21089MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.Unlisted: Procedure/service not specifically defined or classified, maybe subject tocontract/clinical review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review.Check EIU policy CPCP028, which is one of our Clinical Payment and Coding Policy(CPCP).EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review.Check EIU policy CPCP028, which is one of our Clinical Payment and Coding Policy(CPCP).MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review.Check EIU policy CPCP028, which is one of our Clinical Payment and Coding Policy(CPCP).Unlisted: Procedure/service not specifically defined or classified, maybe subject tocontract/clinical review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit forpredetermination to avoid post-service review.SUR701.018Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic TumorsSUR716.017Surgical Treatment of 09SUR717.001SUR716.011SUR717.001SUR716.011Gender Assignment Surgery and Gender Reassignment Surgery with Related ServicesRisk-Reducing (Prophylactic) MastectomyGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesMastopexyReconstructive and Contralateral MammaplastyCosmetic and Reconstructive ProceduresGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesReconstructive and Contralateral MammaplastyReduction MammoplastyGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesReconstructive and Contralateral MammaplastyBreast Implant, Removal and/or InsertionReconstructive and Contralateral MammaplastyBreast Implant, Removal and/or InsertionReconstructive and Contralateral MammaplastyBreast Implant, Removal and/or InsertionGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesReconstructive and Contralateral MammaplastyBreast Implant, Removal and/or InsertionGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesReconstructive and Contralateral MammaplastyGender Assignment Surgery and Gender Reassignment Surgery with Related ServicesReconstructive and Contralateral MammaplastySUR716.001Cosmetic and Reconstructive ProceduresSUR716.011Reconstructive and Contralateral MammaplastySUR716.011Reconstructive and Contralateral MammaplastySUR716.011Reconstructive and Contralateral MammaplastySUR716.011Reconstructive and Contralateral MammaplastySUR716.009SUR716.011Breast Implant, Removal and/or InsertionReconstructive and Contralateral MammaplastyAdipose-Derived Stem Cells in Autologous Fat Grafting to the BreastHandheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During BreastConserving SurgeryMagnetic Resonance Image Guided Laser Interstitial Tumor Therapy (LITT)Reconstructive and Contralateral 1Clostridial Collagenase for Fibroproliferative DisordersDry Needling of Trigger Points for Myofascial PainSUR702.018Dry Needling of Trigger Points for Myofascial PainDME101.030Low Intensity Pulsed Ultrasound Fracture Healing DeviceSUR701.021Radiofrequency Ablation (RFA) of Solid Tumors, Excluding LiverSUR701.018Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic TumorsSUR705.023Computer-Assisted Navigation for Orthopedic ProceduresTHE803.016SUR705.010Manipulation Under AnesthesiaTemporomandibular Joint (TMJ) Disorders (TMJD)SUR706.009Sleep Related Breathing Disorders: Surgical ManagementMP Criteria: Procedure/service reviewed against Medical Policy Criteria, may requirePrior Authorization per contract ic SurgerySleep Related Breathing Disorders: Surgical ManagementTemporomandibular Joint (TMJ) Disorders (TMJD)Unlisted: Procedure/service not specifically defined or classified, maybe subject tocontract/clinical 705.010SUR717.001SUR705.030SUR717.001
00797 Anesth Surgery For Obesity MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit for predetermination to avoid post-service review. SUR716.003 Bariatric Surgery _ _ 07957 Weight Loss Non Covered: Procedure/service not covered by the Plan. Not subject to pre-service review. _ _ _ 9/30/2021 11920 Correct Skin Color .
