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.