Prior Authorization

Documentation

For more information on coverage and documentation requirements, refer to:

Blepharoplasty, Blepharoptosis Repair and Brow Ptosis Repair*

Code Description
15820 Removal of excessive skin of lower eyelid
15821 Removal of excessive skin of lower eyelid and fat around eye
15822 Removal of excessive skin of upper eyelid
15823 Removal of excessive skin and fat of upper eyelid
67900 Repair of brow ptosis
67901 Repair of upper eyelid muscle to correct drooping or paralysis
67902 Repair of upper eyelid muscle to correct drooping or paralysis
67903 Shortening or advancement of upper eyelid muscle to correct drooping or paralysis, internal
67904 Repair of tendon of upper eyelid, external approach
67906 Suspension of upper eyelid muscle to correct drooping or paralysis
67908 Removal of tissue, muscle, and membrane to correct eyelid drooping or paralysis

 

*CPT 67911 (Correction of lid retraction) was removed on January 7, 2022

Botulinum Toxin Injection

Code Description
64612 Injection of chemical for destruction of nerve muscles on one side of face
64615 Injection of chemical for destruction of facial and neck nerve muscles on both sides of face
J0585 Injection, onabotulinumtoxina, 1 unit
J0586 Injection, abobotulinumtoxina
J0587 Injection, rimabotulinumtoxinb, 100 units
J0588 Injection, incobotulinumtoxin a

 

Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services

CPT/HCPCS Code Description
15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (list separately in addition to code for primary procedure)
15877 Suction assisted removal of fat from trunk

 

Rhinoplasty and Related Services

CPT/HCPCS Code Description
20912 Nasal cartilage graft
21210 Repair of nasal or cheek bone with bone graft
30400 Reshaping of tip of nose
30410 Reshaping of bone, cartilage or tip of nose
30420 Reshaping of bony cartilage dividing nasal passages
30430 Revision to reshape nose or tip of nose after previous repair
30435 Revision to reshape nasal bones after previous repair
30450 Revision to reshape nasal bones and tip of nose after previous repair
30460 Repair of congenital nasal defect to lengthen tip of nose
30462 Repair of congenital nasal defect with lengthening of tip of nose
30465 Widening of nasal passagebsp
30520 Reshaping of nasal cartilage

 

Vein Ablation and Related Services

CPT/HCPCS Code Description
36473 Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance
36474 Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance
36475 Destruction of insufficient vein of arm or leg, accessed through the skin
36476 Radiofrequency destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance
36478 Laser destruction of incompetent vein of arm or leg using imaging guidance, accessed through the skin
36479 Laser destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance
36482 Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance
36483 Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance

 

Cervical Fusion with Disc Removal

CPT/HCPCS Code Cervical Fusion with Disc Removal
22551 Fusion of spine bones with removal of disc at upper spinal column, anterior approach, complex, initial
22552 Fusion of spine bones with removal of disc in upper spinal column below second vertebrae neck, anterior approach, each additional interspace

 

Implanted Spinal Neurostimulators

CPT/HCPCS Code Implanted Spinal Neurostimulators
63650 Implantation of spinal neurostimulator electrodes, accessed through the skin

 

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