When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
11920, 11921, 11922, 11970, 11971, 15271, 15272, 15769, 15772, 15777, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396
THE FOLLOWING CODE IS USED TO REPRESENT ADIPOSE DERIVED STEM CELL ALONE OR IN CONJUNCTION WITH AUTOLOGOUS FAT GRAFTING IN RECONSTRUCTIVE BREAST SURGERY:
Policy: 11.08.03j:Lipectomy and Liposuction
Policy: 11.08.05g:Application and Removal of Tattoos
Policy: 11.08.14k:Removal of Breast Implants
Policy: 11.08.19o:Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy
Policy: 11.08.20v:Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds