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Anesthesia prior authorization for reconstructive breast procedures

Is Preauth Required? Preauthorization may be required for anesthesia services related to reconstructive breast procedures, such as broken or failed implant, infection, implant extrusion, siliconoma or granuloma, interference with diagnosis of breast cancer, and painful capsular contracture with disfigurement. Will the claim be denied? A claim for anesthesia related to reconstructive breast procedures will be approved because anesthesia is a necessary part of these procedures. When is the following treatment medically necessary for the condition specified? Anesthesia is medically necessary for reconstructive breast procedures to help make the procedure less painful and to reduce risk of infection. What would make the following treatment considered medically necessary? According to Title XVIII of the Social Security Act, Section 1862 (a)(10), anesthesia is considered medically necessary in the context of reconstructive breast procedures. The Compliance with the provisions in this LCD may be monitored and addressed through post payment data analysis and subsequent medical review audits. What are the relevant codes for the treatment? The CPT/HCPCS codes for anesthesia that complement the Local Coverage Determination (LCD) for Continuous Peripheral Nerve Blocks (CPNB) L37641 include: 64416, 64446, 64448, 64449. The ICD-10-CM codes that support medical necessity and provide coverage for CPT codes 19300 for Mastectomy for Gynecomastia are: N62.


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