For Dates of Service Before January 1, 2021

Restorative Plastic Surgery and Procedures

ForwardHealth covers restorative plastic surgeries and procedures when medically necessary per Wis. Admin. Code § DHS 101.03(96m); however, PA is required for coverage of certain surgeries and procedures.

Note: PA is not required for reconstruction after surgery for breast cancer.

The following table lists allowable CPT procedure codes for restorative plastic surgery and procedures that require PA.

Surgery
CPT Procedure Code(s) Service Description
11200-11201 Removal of skin tags
11920-11922 Tattooing
11950-11954 Subcutaneous injection of filling material (eg, collagen)
15771-15774* Grafting of autologous fat or soft tissue
15780-15782 Dermabrasion
15786-15793 Abrasion and chemical peels
15820-15823 Blepharoplasty
15824-15829 Rhytidectomy
17360 Chemical exfoliation for acne (eg, acne paste, acid)
19316* Mastopexy
19324-19325* Mammaplasty, augmentation
19355 Correction of inverted nipples
19340-19369* Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19380* Revision of reconstructed breast
19396* Preparation of moulage for custom breast implant
21083** Impression and custom preparation; palatal lift prosthesis
21087** Nasal prosthesis
21120-21123** Genioplasty
21137 Reduction forehead; contouring only
21270** Malar augmentation, prosthetic material
21280-21282 Medial or lateral canthopexy
30120 Excision or surgical planing of skin of nose for rhinophyma
30400-30450 Rhinoplasty
67900-67909 Repair of brow ptosis, repair of blepharoptosis
69300 Otoplasty, protruding ear, with or without size reduction

* Prior Authorization is not required for these procedures if they are performed following a mastectomy for breast cancer and if the claim includes an allowable breast cancer or personal history of breast cancer diagnosis code.

** Prior Authorization is required to process claims for DME related to these procedures. The DME Index includes the PA requirements for DME.