Prior Approval (PA) Criteria For Surgical Procedures

Many procedure codes require prior authorization (PA) before reimbursement will be made by the Medical Assistance program. A list of these codes appears in Section 600-10 of the Provider Reference Manual. Following are the criteria that must be met for approval of PA requests.

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 outlined in Section 200-30 of the Provider Reference Manual.

Augmentation Mammoplasty

Definition

Cosmetic or cosmetic-like reconstruction of the breast designed to increase the size of or improve the contour or symmetry of the breasts.

Procedure Codes Affected

Approval Criteria

1. Injury or disease which causes breast destruction/distortion is covered.
2. Previous non-cosmetic surgeries that have distorted the breasts severely are accepted
3. The following information must be provided:
   1. Medical necessity for the procedure
   2. All supporting medical documentation for the patient condition
   3. HCPCS code for the procedure requested

Denial Criteria

1. Augmentation mammoplasties performed solely for cosmetic purposes are not covered.
2. None of the approval criteria is met.

Length Of Authorization: 1 Year

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 formation or reformation of the breast designed to improve the contour or symmetry of the breasts.

Procedure Codes Affected

Approval Criteria

1. Injury or disease which causes breast tissue destruction, disfigurement or distortion.
2. Past surgeries that have distorted the breasts severely.
3. The following information must be included:
   1. A statement of medical necessity
   2. Medical documentation of the recipient’s condition
   3. HCPCS code for the procedure requested

Denial Criteria

1. Procedures performed solely for cosmetic purposes are not covered.
2. None of the approval criteria is met.

Length Of Authorization: 1 Year

Dermabrasion

Definition

Surgical abrasion of the surface of the skin designed to remove or improve the appearance of scars, tattoos or keratoses. A scar is a mark remaining after the healing of a wound. A tattoo is the introduction, by punctures, of permanent colors in the skin. Keratoses is any horny growth, such as a wart or callosity.

Procedure Codes Affected

Approval Criteria

1. Procedures related to injury, disease, or growth and development causing the disfigurement are covered.
2. Correction of congenital deformities or anomalies will be covered.
3. A photograph of the involved area indicates severe disfigurement
4. A psychiatrist’s or psychologist’s statement certifies that dermabrasion is necessary to stabilize the recipient’s psychiatric state and enhance vocational opportunities.
5. Diagnosis codes 701.4 (keloid scar) and 709.2 (scars, excluding keloids) need prior authorization.
6. The following information must be provided:
   1. Medical necessity for the procedure
   2. Location, size and cause of the scar
   3. Pre-operative photographs & estimate of number of treatments
   4. CPT and diagnosis codes

Denial Criteria

1. Excision or treatment or scars, tattoos, or keratoses performed solely for cosmetic purposes is not covered.
2. None of the approval criteria is met.

Length Of Authorization: 1 Year

Gastric Bypass Surgery

Definition

Gastrointestinal bypass surgery is a procedure for weight reduction in a morbidly obese individual. The procedure bypasses the stomach and/or portions of the gastrointestinal tract as a method for weight reduction. This type of surgery will limit the amount of nutritional absorption.

Procedure Codes Affected

Approval Criteria

1. Treatment for morbid obesity is covered when the individual is 50% above or 100 pounds over their ideal body weight, whichever is greater, according to a table of desired weight. The duration of obesity must exceed three years, though non- consecutive years are acceptable. One or more of the following conditions must be present:
   1. Physical trauma caused by excess weight
   2. Pulmonary and circulatory insufficiencies
   3. Complications related to the treatment of conditions such as arteriosclerosis, diabetes, coronary disease, etc.
2. Surgical procedures will be approved for recipients between the ages of 18 and 60 years old.
3. A second operation to restore the gastrointestinal tract to normal (or as near to normal as possible), when medically necessary, is covered.
4. The following information must be included:
   1. A detailed history of the recipient including height, weight, duration of obesity, and concurrent diagnosis of the recipient
   2. Information ruling out other correctable causes of obesity
   3. Documentation regarding other gastric surgeries and failed attempts at weight loss

Denial Criteria

1. Restoration of the gastrointestinal tract to normal or as near as possible when not medically necessary is not covered.
2. Other procedures performed for cosmetic reasons due to the weight loss are not covered.
3. Weight loss centers or diet centers are not covered.
4. Insertion and/or removal of the Gastric Bubble, including dietary behavioral modification, is not covered.

Length Of Authorization: 1 Year

Panniculectomy And Lipectomy

Definition

Panniculectomy is defined as an excision of the excessive skin and subcutaneous tissue. Lipectomy is defined as the excision of fatty tissues.

Procedure Codes Affected

Approval Criteria

1. . Surgery will be considered only if all of the conditions below are present:
   1. Recipients whose body weight is in excess of 100 lb. over the current height and weight chart
   2. Diagnosis of insulin-dependent diabetes mellitus
   3. Medical documentation of serious problems with infection control
   4. Recipients in whom the panniculus is causing prolapse of a ventral hernia
   5. Severe Cardiovascular disease is present and affected by weight
   6. Respiratory impairment related to obesity
2. The following information must be provided:
   1. Recipient’s height, weight and frame size, including documentation of any previous attempts of weight loss
   2. Documentation of any functional problems (mobility, interference with potential employment, etc.) that may indicate a need for the surgery
   3. Pre-operative photographs, chin to waist, including standing frontal, anterior and side views with arms by side.

Denial Criteria

1. Procedures performed solely for cosmetic purposes are not covered
2. None of the approval criteria is met.

Length Of Authorization: 1 Year

Penile Prosthesis

Definition

Surgical insertion of a prosthetic device, the purpose of which is to contribute to a penile erect state. The types of prostheses include the rod and inflatable types.

Procedure Codes Affected

Approval Criteria

1. Penile prosthesis implantation is covered for the treatment of impotence causing significant physical problems or in neurological disease requiring an external catheter.
2. The cause of a recipient’s impotence should be determined prior to considering approval of surgical intervention. Nocturnal tumescence monitoring (phallography) results are helpful in distinguishing between psychological and physical impotence.
3. The following information must be included:
   1. The patient’s age and history of impotence, including the duration and circumstances surrounding the onset)
   2. Any systemic or vascular disease or neurological disorder present
   3. A history of any drug or alcohol dependence and any medications the patient is currently taking
   4. Any psychological or physical evaluations performed
   5. The benefits or improved condition expected as a result of the insertion of the penile prosthesis

Denial Criteria

1. Implantation of a penile prosthesis for impotence due strictly to psychological factors is not covered.
2. None of the above criteria is me.

Length Of Authorization: 6 Months

Radiology Services

Billing Guidelines

Radiology services can be billed by the physician as a complete or a professional component. The professional component must be noted through billing the CPT procedure code in conjunction with the modifier “26”. Radiology services for the technical component (modifier “TC”) are paid only to the facility.

Complete Procedure

A complete procedure includes both the professional and the technical components of a radiological procedure and is limited to an office or nursing home setting only. If the provider renders the complete procedure in the nursing home, the provider must supply their own portable equipment.

There is a limit of one complete procedure per code per recipient per day.

Multiple Procedures

Multiple units of radiological procedures are allowed on the same day if:

• billing is for professional component only, and;
• procedures are performed in an inpatient or outpatient setting; and/or the diagnosis medically justifies multiple (like) procedures

Portable X-Ray Procedures

Portable x-ray services must be performed under the general supervision of a physician and conditions of health and safety must be met.

Coverage for portable x-ray includes skeletal films involving arms and legs, pelvis, vertebral column and skull; chest films not involving the use of contrast media (except routine screening procedures and tests in connection with routine physical examination), and abdominal films which do not include the use of contrast media.

Procedures and examinations which are not covered under the portable x-ray provision include procedures involving fluoroscopy, the use of contrast media, requiring the administration of a substance to the patient or injection of a substance into the patient and/or special manipulation of the patient, requiring special medical skill or knowledge possessed by a doctor of medicine or doctor of osteopathy or requiring medical judgment to be exercised requiring special technical competency and/or special equipment or materials, routine screening procedures and procedures which are not of a diagnostic nature

Portable x-ray tests must be provided on the written order of a physician. Claims for services involving the chest must contain the name of the physician who ordered the service and the reason the x-ray test was required.

An electrocardiogram tracing by an approved supplier of portable x-ray services may be covered as an other diagnostic test. Portable EKG services must be provided on the written order of a physician.

Procedure Codes Affected

R0070 is used to bill for transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility, regardless of the number of patients seen.

R0076 is used to bill for portable EKG to facility or location, per trip, regardless of the number of patients seen.

Reduction Mammoplasty

Definition

Cosmetic or cosmetic-like reconstruction of the breast designed to reduce the size.

Procedure Codes Affected

Approval Criteria

1. The recipient weighs no more than 120% of his/her ideal weight.
2. The request indicates at least 450 Grams of tissue per breast is to be resected.
3. The following information must be provided
   1. Complete history and physical, including height, weight, and bra size
   2. Four or more of the following symptoms must be present:
      1. Shoulder pain
      2. Shoulder grooving
      3. Upper back and neck spasms and pain
      4. Lower chronic back pain and discomfort
      5. Submammary intertrigo (rashes and irritation underneath the breast near the chest wall)
      6. Inability to sleep in a recumbent position associated with shortness of breath (only in gigantomastias)
   3. Triangular measurement from the suprasternal notch to the nipples. This measurement must be greater than 8 cm. above the normal range of 18-20 cm.
   4. Functional debility caused by the condition.
   5. Pre-operative photographs, chin to waist, including standing frontal and side views with arms by side
   6. HCPCS code for the procedure requested

Denial Criteria

1. Reduction mammoplasties performed solely for cosmetic reasons (i.e., to equalize breast size) will be denied.
2. Complications due to previous surgery, performed solely for cosmetic purposes, are not covered.
3. Prosthetic implants are not covered.

Length Of Authorization: 1 Year

Rhinoplasty And Septorhinoplasty

Definition

Rhinoplasty is a plastic surgical operation on the external nose for reconstructive, restorative or cosmetic purposes. Septorhinoplasty is the same procedure as rhinoplasty, but it also includes surgery on the nasal septum.

Procedure Codes Affected

Approval Criteria

1. Surgery for the repair of nasal deformity secondary to congenital cleft lip and/or palate is covered.
2. These procedures are covered for nasal obstruction or hyperpharynx leading to serious impairment of adequate nasal breathing and/or drainage.
3. The following information must be provided:
   1. Medical necessity for the procedure
   2. Location and degree of obstruction of air passage
   3. HCPCS code for the procedure requested

Denial Criteria

1. Septoplasty alone does not require prior authorization
2. Rhinoplasty for cosmetic purposes only is not covered
3. None of the approval criteria is met

Length Of Authorization: 1 Year