Prior Approval (PA) Criteria For Surgical Procedures

Many procedure codes require prior authorization (PA) before reimbursement will be made by the Medicaid program.

Retroactive authorization is not normally granted on a routine basis. However, it is possible to obtain such approval on a case-by-case basis. Instructions for obtaining prior approval are on the Prior Authorization page.

Augmentation Mammoplasty

Definition

Augmentation mammoplasty is the surgical enlargement of the breast, either to increase breast size or replace a full or partial breast that has been surgically removed.  The augmentation is done by utilizing autogenous tissue such as a muscle flap graft or by inserting a liquid filled prosthesis.

Coverage Guidelines (prior authorization is required):

1. Documented clinical evidence of surgery for benign disease when a subcutaneous mastectomy is performed with immediate or delayed prosthesis; or
2. Documented clinical evidence of a previous mastectomy for benign or malignant disease including the unaffected breast to provide symmetry with the breast on which the radical or modified mastectomy was performed.

Procedures performed for solely cosmetic purposes are not covered.

Prior Authorization shall be valid for 12 months from date of issuance.

Click here for an approved PDF version of the Augmentation Mammoplasty policy.

Bariatric Surgery

Bariatric surgery is performed for long term weight management in individuals diagnosed with severe or morbid obesity.  Two categories of procedures are applicable:

1. Gastric-restrictive procedures designed to create a small gastric pouch resulting in weight loss produced by early satiety and decreased caloric intake.
2. Malabsorptive procedure designed to reult in weight loss by altering the normal transit of food through the intestine and subsequent malabsorption.
3. Combination procedures may incorporate elements of both therapeutic processes.

Clinically severe obesity is defined as a BMI 35-39.9 kg/m².  Morbid obesity is denied as a BMI greater than or equal to 40 kg/m².

Clinical Guidelines (prior authorization is required for all bariatric procedures)

1. BMI greater than or equal to 40 kg/m²; or
2. BMI between 35 and 39.9 kg/m² and a least one of the following co-morbidities is present:
   
   a.  Arteriosclerosis, Diabetes, heart disease; or
   
   b.  Limitation of motion in any weight-bearing joint or lumbosacral spine as documented in the clinical health care record and radiologic documentation; or
   
   c.  Significant respiratory insufficiency as evidenced by pCO2> 50 mmHg, resting pO2< 55 mmHg on room air; FEV1/FVC < 65%, evidence of Obesity Hypoventilation Syndrome or documented Sleep Apnea; or
   
   d.  Documented Peripheral Vascular Disease, Coronary or Carotid Artery Disease, severe valvular disease; or
   
   e.  Refractory Hypertension; or
   
   f.  Hypercholesterolemia > 240 mg/dL or hypertriglyceridemia > 400 mg/dL, or low density lipoprotein > 160 mg/dL, or high density lipoprotein < 40 mg/dL despite appropriate medical therapy.
3. Clinical health documentation must be submitted which include the following:
   
   a.  Documenation of clinically severe or morbid obesity for the past three years.
   
   b.  Failure of an intensive, structured, non-surgical weight loss program during the 2 years preceding the request.
   
   c.  Correctable causes for obesity have been ruled out.
   
   d.  There has been multidisciplinary team approach to prior evaluation and management of the recipient's obesity.
   
   e.  Plan exists for post surgical follow-up by multidisciplinary team and documentation of patient agreeing to post procedure follow-up plan.
4. Revision of Bariatric Surgery
   
   Medically necessary surgery to correct complications from the initial bariatric surgery will be reviewed on an individual basis.  Revisions to the initial procedure may be covered for a recipient if one of the following conditions is met:
   
   a.  Weight loss of 20% or more below the ideal body weight;
   
   b.  Hemorrhage or hematoma complicating a procedure;
   
   c.  Excessive bilious vomitting;
   
   d.  Complications of anastomosis and bypass;
   
   e.  Slippage of adjustable gastric band;
   
   f.  Pouch dilation producing weight gain of 20% or more.  Provided that:
   
   1.  Primary procedure was successful in producing weight loss, and 
   
   2.  Recipient has been compliant with post procedure nutrition and exercise program.
   
   g.  Stricture, obstruction or staple line failure.
   
   h.  Significant metabolic disturbance post procedure.
   
   
   
   Cosmetic Follow-up
   
   Surgical removal of skin and fat folds evident post weight loss for solely cosmetic purpose is not covered.
   
   
   
   Prior Authorization shall be valid for 12 months from date of issuance.
   
   
   
   Click here for an approved PDF version of the Bariatric Surgery Policy.

Blepharoplasty

Definition

Cosmetic surgical correction and improvement of the skin and subcutaneous tissues of the upper and lower eyelids.

Procedure Codes Affected

Approval Criteria

1. Upper lid blepharoplasty is covered only if the recipient has any of the following:
   1. Blepharoptosis (eyelid drooping below the normal level with resulting obstruction of the field of vision and/or positional head changes)
   2. Blepharochalasis (relaxation of the skin of the eyelid due to loss of elasticity of the intercellular tissue)
   3. Exposure keratitis (inflammation of the cornea)
2. Lower eyelid blepharoplasty is covered for exposure keratitis only.
3. The following information must be provided:
   1. A physician’s statement, signed and dated, describing specific visual impairment
   2. Full-range visual field test results which demonstrate a 30 degree or lower obstruction in the superior part
   3. Preoperative photographs of the eyes and surrounding tissues

Denial Criteria

1. Blepharoplasty performed solely for cosmetic purposes is not covered.
2. Ectropion (eversion or turning outward of the eyelid) and entropion (inversion or turning inward of the eyelid) procedures do not require prior authorization.
3. None of the approval criteria is met.

Length Of Authorization: 1 Year

Breast Reconstruction

Definition

Surgical procedures that are designed to restore the normal appearance of the breasts after surgery, such as mastectomy or lumpectomy, and surgical procedures used to restore, correct or improve anatomical and/or functional impairments that result from accidental injury, previous surgery, therapeutic interventions, or disease of the breast.

Coverage Guidelines:

1. Documented evidence of injury or disease which causes breast tissue destruction, disfigurement or distortion; or 
2. Reconstruction is secondary to mastectomy or lumpectomy (for breast cancer or prophylaxis for breast cancer); or
3. Treatment of lymphedema.

Procedures performed solely for cosmetic purposes are not covered.

Prior Authorization shall be valid for 12 months from date of issuance.

Click here for an approved PDF version of the Breast Reconstruction Policy.

Dermabrasion

Definition

Dermabrasion is a method of controlled scraping of the skin typically using a diamond fraise, burrs, rasp sandpaper,  or similar device.  This procedure is generally limited to the face.

Coverage Guidelines (prior authorization is required):

1. Documentation of Actinic Keratosis.
2. Documentation of other precancerous lesions limited to epidermis or superficial dermis.
3. Scar related to accident, injury, or previous surgery.

NOTE:  Procedures performed to remove scars, Acne scaring, wrinkles, tattoos or for cosmetic reasons are not covered.

Prior authorization shall be valid for 12 months from the date of issuance.

Click here for an approved PDF version of the Dermabrasion Policy.

Gender Dysphoria/Gender Nonconformity Coverage Guidelines

Gender Nonconformity - extent to which a person's gender identity, role or expression differs from cultural norms prescribed for people of a particular sex and Gender Dysphoria - discomfort or distress that is caused by a discrepancy between the person's identity and that person's sex at birth.

These guidelines are not intended to address specific treatment choices for individual beneficiaries.

Coverage Guidelines

Non Covered Services include but are not limited to:

1. Gender reassignment services for members who are dissatisfied with their natal sex or prefer to be opposite sex without clinically significant distress or impairment.
2. Cosmetic procedures.
3. Reversal of gender reassignment surgery.
4. Procedures for the preservation of fertility such as the procurement, preservation and storage of sperm, oocytes, embryos.

Required documentation for prior authorization requests:

1. Documentation of persistent Gender Dysphoria.
2. Inclusion of a specific management plan for medical and behavioral health concerns as documented by the treating clinician.
3. Attestation by the provider that the record includes an informed consent agreement signed by the member and that the document includes a summary of required post procedure management and screenings.
4. Documentation of appropriate Behavioral Health assessment and counseling.
5. Documentation of face to face evaluation within 30 days of the prior authorization request being submitted, which includes clinical history, summary of prior therapies, plan for ongoing and post procedure management and the presence of necessary post procedure support services.

Covered services for members age 18 and older:

1. Behavioral Health
2. Hormonal therapy
3. Laboratory testing required to monitor hormonal therapy
4. Surgical procedures included in list below.  PRIOR AUTHORIZATION IS REQUIRED FOR THESE PROCEDURES.

The following procedures are covered for females transitioning to males:

Hysterectomy

Mastectomy

Metoidioplasty

Phallic reconstruction/Phalloplasty

Testicular prosthesis implantation

Salpingo-oopherectomy

Urethroplasty

Vaginectomy

The following procedures are covered for males transitioning to females:

Vulvoplasty

Clitoroplasty

Orchiectomy

Penectomy

Vaginoplasty

Colovaginectomy

Breast augmentation (when the member is not comfortable in social role after 12 months of hormonal therapy).

Covered services for members age 17 or younger:

1. Behavioral Health
2. Pharmacological and hormonal therapy to delay physical changes of puberty to masculinize or feminize.  REQUIRES PRIOR AUTHORIZATION.
3. Non-reversible hormonal therapy.  REQUIRES PRIOR AUTHORIZATION.

Click here for the approved PDF version of the Gender Dysphoria Coverage Guidelines.

Panniculectomy/Abddominoplasty

A panniculectomy is a surgical procedure to remove the panniculus or excess skin and fat that forms an abdominal apron.  It includes the removal of excessive skin, subcutaneous tissue and fat.

Abdominoplasty is a surgical procedure such as a panniculectomy that includes tightening of the abdominal muscles.

Coverage and Payment Policy

This service requires prior authorization.

Approval criteria:

1. Beneficiary is age 18 or older.
2. The beneficiary has had substantial weight loss that is stable for at least 6 months.
3. The panniculus causes chronic and persistent skin condition that has not responded to 6 months or more of conventional treatment.
4. The panniculus hangs to or below the level of the symphysis pubis.
5. The panniculus either:
   
   a.  Significantly interferes with mobility or activities of daily living; or
   
   b.  Contributes substantially to a recurrent or extensive incisional hernia or ventral hernia.

The following clinical information must be submitted by the surgeon involved in the beneficiary's care:

1. Documentation of a comprehensive history and physical examination which includes the following:
   
   a.  Member's age and BMI;
   
   b. Clinical history pertinent to the diagnosis including any interference with mobility or activities of  daily living;
   
   c.  Previous and current use of prescribed and over-the-counter medications used specifically for dermatologic problems associated with the panniculus;
   
   d.  Risk factors and co-morbid conditions; and
   
   e.  Previous relevant hospitalizations and surgeries.
2. The panniculectomy may occur simultaneously with biopsy proven cancer to optimize surgical field exposure.

Non-coverage:

1. Procedure is for cosmetic purposes.
2. Panniculectomy is requested to be done simultaneously with gastric bypass surgery.
3. The member has difficulty in fitting clothes.
4. When panniculectomy is to be performed to relieve back pain.

Click here for an approved PDF version of the Panniculectomy/Abdominoplasty coverage guidelines.

Reduction Mammoplasty

Definition

Breast reduction involves removal of glandular, fatty and skin tissue from the breast.  The procedure is performed in order to alleviate or correct medical problems caused by excessive breast tissue.  Women presenting various forms of breast hypertrophy accompanied by persistent clinical signs and symptoms that adversely affect health are the principle candidates for breast reduction.

Coverage Guidelines (prior authorization is required)

1.  Documentation of symptoms being unresponsive to medical therapies such as physical therapy, use of support garment or brace, conservative analgesia and correction of Obesity (BM I=/> 30) for a minimum of 6 months prior to request for authorization.

2.  Functional disability (adverse effect on activities of daily living) related to at least one of the following:

Documentation of back, neck, and/or shoulder pain; or

Documentation of significant arthritic changes in the cervical or upper thoracic spine; or 

Shoulder grooving; or

Intertriginous maceration or infection of inflamed skin refractory to medical therapy; or

Signs and symptoms of ulnar paresthesia documented by nerve conduction studies.

3.  Reduction mammoplasty performed to achieve symmetry following removal and/or reconstruction of a breast due to malignancy.

4.  Documentation of anticipated amount (in grams) of breast tissue to be removed based on body surface area.  Body surface area calculator is available at MedCalc: Body Surface Area, Body Mass Index (BMI).  It is recognized that arbitrary minimum weight of breast tissue removed does not consistently reflect the consequences of mammary hypertrophy in individuals with unique body habitus.  Therefore, this policy incorporates the signs and symptoms and physical findings indicated above for the determination of medical necessity.

Reduction mammoplasty will not be covered when performed for cosmetic indications.

Prior authorization shall be valid for 12 months from date of issuance.

Click here for an approved PDF version of the Reduction Mamoplasty policy

Rhinoplasty and Septoplasty

Definition

Rhinoplasty is an operation on the nose to correct nasal contour and/or restore nasal respiratory function.

Septoplasy is an operation involving only the septum.

Septorhinoplasy is an operation combining both procedures and involving the nasal skeleton and repairs to the septum due to a functional impairment involving both structures.

Coverage Guidelines (prior authorization is required):

One of the following criteria below must be present:

1. Septal deviation causing continuous nasal airway obstruction resulting in breathing difficulty not responsive to medical therapy; or
2. Deformity of the bony nasal pyramid that directly causes significant symptomatic airway compromise, sleep apnea, or recurrent rhinosinusitis unresponsive to medical therapy; or
3. Recurrent sinusitis felt to be secondary to a deviated septum and unresponsive to medical therapy; or
4. Recurrent epistaxis related to a septal deformity; or 
5. Reconstruction secondary to removal of a nasal malignancy, abscess or osteomyelitis that has caused severe breathing difficulty or deformity; or
6. Significant deformity caused by recent trauma.

Procedures performed solely for cosmetic purposes are not covered.

Prior authorization shall be valid for 12 months from date of issuance.

Click here for an approved PDF version of the Rhinoplasty and Septoplasty policy.