Does simply healthcare cover therapy

Integrated health care

Simply Healthcare Plans, Inc. (Simply) facilitates integrated physical and behavioral health services as a vital part of health care. Our mission is to address the physical and behavioral health care of members by offering a wide range of targeted interventions, education and enhanced access to care to ensure improved outcomes and quality of life for members. We work collaboratively with hospitals, group practices, independent behavioral health care providers, community, government agencies, human service districts and other resources. This enables Simply to successfully meet the needs of members with mental health and substance use disorders as well as those with intellectual and developmental disabilities.

Telehealth Resources

• Contact Chrysalis Health by sending the first page of this form via Fax: (954)587-0080 or Email:[email protected]; Website:  https:\www.ChrysalisHealth.com - For questions call 1-888-587-0335
• Contact Brave Health at [email protected] or 305-902-6347

Related resources

Beacon Phone Numbers for Members and Providers:

• 1-844-375-7215: Medicaid 
• 1-855-861-2142: Florida Healthy Kids
• 1-877-698-7787: Medicare
• 1-786-837-2850: Providers wanting to join Beacon Network

 
Preauthorizations:  

• 1-800-221-5487: IP, IOP, PHP, SIPP, RTC  
• 1-844-375-7215: OP Medicaid
• 1-855-861-2142: FHK

 
Beacon Fax Numbers:

• IP, IOP, PHP, SIPP, RTC Preauthorization:  We do not accept faxes for this LOC, only phone calls.    
• 1-800-370-1116: Medicare Preauthorization
• 1-800-370-1116: Medicaid Outpatient Preauthorization

 
Join Network for Providers

• 1-786-837-2850

 
Crisis Calls for Members

• 1-844-375-7215, Press 9, Press 1 for English or 2 for Spanish, Press 9 for Emergency, will then be transferred to a clinician

Deciding to see a therapist may have been difficult, but finding one who accepts your insurance may be even more challenging. And while you’re trying to cope with your own mental and emotional issues, dealing with insurance issues may be the last thing you want to do.

At Mental Health Match, we specialize in matching people to therapists near you who accept or are in-network with Simply Healthcare.

Whether you are located in downtown Tampa, Carver City Lincoln Gardens,Courier City Oscawana, Drew Park, or even East Ybor, Mental Health Match can help you easily find an experienced therapist or counselor who best meets your needs.

Does Your Insurance Cover Therapy?

Before you start therapy, the first thing you should do is verify your outpatient Simply Healthcare therapy coverage. If your plan doesn’t cover behavioral health therapy, they won’t pay; it may surprise you how many plans don’t include therapist insurance coverage.

To determine what your plan covers, you can call the customer service number on your insurance card. Once you know for sure that your insurance will cover outpatient behavioral health, leave it to us to help you find a therapist who accepts Simply Healthcare plans.

If you would like to learn more about how to use insurance to cover therapy, check out our FAQ about how to pay for therapy.

Find a Therapist Near You Who Accepts Simply Healthcare Therapy Coverage

Instead of Googling “therapists that take my insurance” and sifting through tons of results to no avail, allow us to help. After all, the longer you spend trying to figure out how to pay for therapy, the longer your treatment may be delayed.

With Mental Health Match, finding a qualified therapist near you who takes Simply Healthcare therapy coverage is easy! Start by browsing in-network experts below or by using our free therapist matching tool.

Tampa, FL Therapists In-Network with Simply Healthcare – List Your Practice on Mental Health Match

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Medical PolicySubject: Cosmetic and Reconstructive Services: Skin RelatedDocument #: ANC.00007Publish Date: 07/06/2022Status: RevisedLast Review Date: 05/12/2022 Description/Scope

This document addresses the cosmetic, reconstructive, and medically necessary uses of a selection of techniques used in the treatment of skin lesions and related conditions.  

Note: Please see the following related documents for additional information:

Note: This document does not address light therapy (such as laser ultraviolet A or B therapy) to treat vitiligo.

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment AND the procedure can be reasonably expected to improve the functional impairment.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or a congenital defect.

Note: Not all benefit contracts/certificates include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance.

Position Statement

A.      Chemical Peels

Chemical peels (known as epidermal peels or chemotherapy of the skin) are considered medically necessary for active acne.

Medium or deep chemical peels, referred to as dermal peels are considered medically necessary when there is documented evidence of 10 or more actinic keratoses or other pre-malignant skin lesions that have failed topical retinoid treatment, topical chemotherapeutic agents and cryotherapy.

Chemical peels of any type are considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation. Examples include, but are not limited to, treatment of photoaged skin, wrinkles, acne scarring or uneven epidermal pigmentation.

B.      Cutaneous Hemangioma, Port Wine Stain, and other Vascular Lesions

Treatment of cutaneous hemangioma, port wine stain, or other vascular lesions is considered medically necessary when there is documented evidence of significant functional impairment (for example, bleeding or a lesion which interferes with vision) and the procedure can be reasonably expected to improve the functional impairment.

Treatment of cutaneous hemangioma, port wine stain, or other vascular lesions using lasers or other methods to restore appearance is considered reconstructive when intended to address a significant variation from normal related to a congenital defect.

Treatment of cutaneous hemangioma, port wine stain, or other vascular lesions is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment, are not reconstructive, and are intended to change a physical appearance that would be considered within normal human anatomic variation.

C.      Dermabrasion

Dermabrasion (that is, abrasion, salabrasion) is considered medically necessary for the treatment of actinic keratoses, other pre-malignant skin lesions and localized non-melanoma malignant skin lesions. Examples include, but are not limited to, basal cell carcinoma and carcinoma in-situ.

Dermabrasion or salabrasion is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation. Examples include, but are not limited to, enhance the appearance of the upper layer of the skin as a result of acne, acne scars, uneven pigmentation or wrinkles.

D.      Hair Procedures

Permanent removal of hair is considered medically necessary for recurrent infected cyst, hair follicle infections, or after surgical treatment of pilonidal sinus disease.

Hairplasty for alopecia, including but not limited to androgenetic alopecia, and temporary or permanent removal of hair using electrolysis, lasers, or waxing is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation.
 

E.      Laser and Surgical Treatment of Rosacea and Telangiectasia

Laser or surgical management of rosacea is considered medically necessary when the rosacea is severe, refractory to standard medical therapy, and preoperative photos document the clinical skin changes requiring treatment.

Laser or surgical treatment of rosacea or isolated telangiectasias (including spider veins) is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation.

F.      Other Cosmetic Skin Procedures

Laser skin resurfacing is considered cosmetic and not medically necessary for all indications, including but not limited to the treatment of facial wrinkles and skin irregularities (for example, acne scars or blemishes).

Microneedling, also known as percutaneous collagen induction therapy or skin needling, is considered cosmetic and not medically necessary for all indications, including but not limited to the treatment of facial wrinkles and skin irregularities (for example, acne scars or blemishes).

Removal or excision of a tattoo is considered cosmetic and not medically necessary for all indications.

G.     Tattoos (Application)

Tattooing of skin is considered medically necessary when done as part of a medically necessary therapeutic treatment. An example includes, but is not limited to, tattooing related to radiation therapy.

Tattooing of the skin is considered reconstructive when performed as part of a covered breast reconstruction.

Tattooing of skin is considered cosmetic and not medically necessary when the medically necessary or reconstructive criteria in this section are not met.

Rationale

Concepts of Medical Necessity, Reconstructive and Cosmetic

The coverage eligibility of medical and surgical therapies to treat skin conditions is often based on a determination of whether treatment is considered medically necessary, reconstructive or cosmetic in nature. In many instances the concept of reconstructive overlaps with the concept of medical necessity. For example, services intended to correct a significant functional impairment as a result of trauma will be considered medically necessary and thus eligible for coverage, regardless of the contract language pertaining to reconstructive services, unless some other exclusion applies. Generally, reconstructive is often taken to mean that the service “returns the patient to whole” as a result of a congenital anomaly, disease or other condition including post trauma or post therapy, while cosmetic generally describes improving a physical appearance that would be considered within normal human anatomic variation. Categories of conditions without associated functional impairment that may be included as reconstructive include or may be due to the following: a) surgery, b) accidental trauma or injury, c) diseases, d) congenital anomalies, e) severe anatomic variants, and f) chemotherapy.

Background/Overview

Chemical peels

Acne vulgaris is the most common form of acne, occurring in an estimated 85% of the adolescent population in the United States. While, for the most part, the manifestations of acne vulgaris are temporary, severe cases may result in permanent scarring. There are several local factors that contribute to the development of acne vulgaris, including blocked hair follicles, enlargement of specific skin glands, over production of skin glands, use of products that promote bacterial growth, and inflammatory responses to bacterial overgrowth. Other less common causes include hormonal imbalance and some medications. Recommendations for treatment include topical therapy as the standard of care in acne management, with systemic antibiotics as the standard of care in the management of moderate and severe presentations of acne and treatment-resistant forms of inflammatory acne. Intralesional corticosteroid injections are identified as effective in the treatment of individual acne nodules.

Chemical peels are a group of skin procedures used to treat a wide variety of skin conditions including pre-malignant and selected malignant skin lesions, aged skin, wrinkles, acne, acne scarring and uneven epidermal pigmentation. One of several chemical solutions is used (glycolic acid, salicylic acid, lactic acid) which are applied to the skin causing it to “blister” and eventually peel off. The new, regenerated skin is usually free of any lesions and is generally smoother and less wrinkled than the original skin.

Cutaneous hemangioma, port wine stain, and other vascular lesions

Vascular birthmarks are commonly encountered in children and are classified as either hemangiomas or vascular malformations, with cutaneous vascular lesions being the most common pediatric birthmarks. Vascular malformations (flat lesions) include salmon patch (nevus simplex or nevus telangiectaticus) and port wine stain (nevus flammeus), the latter affecting approximately 3 in 1000 children. Hemangiomas (raised lesions) include superficial hemangioma (capillary nevus hemangioma) and deep hemangioma (cavernous hemangioma). Infantile hemangiomas (IHs) are the most common vascular tumors of childhood, affecting 5% of all infants. IHs present in infancy and early childhood; 12% occur in infancy and 42% occur within the first 5 years (Darrow, 2015). Most lesions are characterized by a pattern of rapid proliferation and then involute with minimal consequence and do not require treatment. Semkova and colleagues (2015) note 90% of IH cases experience complete regression by age 9. However, a significant minority of cases can be disfiguring, functionally significant, or, rarely, with severe systemic complications (Glick, 2012; Hartzell, 2012). Some hemangiomas, including those of the nose and lip, are likely to lead to scarring and loss of function when the lesion involutes.

Multiple factors are typically taken into account when determining the appropriate therapy to treat IH. The American Academy of Pediatrics (2015) lists those contributing factors:

1. Age of the patient,
2. Growth phase of the lesion,
3. Location and size of the lesion,
4. Degree of skin involvement,
5. Severity of complication and urgency of intervention,
6. Potential for adverse psychosocial consequences,
7. Parental preference, and
8. Physician experience.

Ulceration is a common complication in proliferation of IH. Typically, topical treatments are initially used to treat IH. IHs may also be treated by a β-blocker (propranolol) or other oral therapies. Surgery and laser treatments are still used in select cases (Krowchuk, 2019). Pulsed dye laser (PDL) may be effective in managing ulcerated IH, however propranolol appears to be associated with faster ulceration healing than laser therapy (Krowchuk, 2019).

Port wine stains (low-flow vascular malformations) are a condition present at birth consisting of superficial and deep dilated skin lesions appearing as flat, faint, pink-red patches. The lesions, comprised of immature, venule-like vasculature, progressively enlarge and darken over time (van Raath, 2020). Port wine stains rarely indicate the presence of a sign of serious health problem except in conditions such as Sturge-Weber or Klippel-Trenaunay-Weber syndrome. Some port wine stains may occasionally bleed with trauma, resulting in potential deformity and disfigurement. Early treatment may prevent the progression of development to hypertrophy and nodules in later years. Evidence in the peer-reviewed medical literature suggests efficacy is increased if lesions are treated in infancy, although size and location are also predictors of outcome (Conlon and Drolet, 2004; Jeon, 2019). Facial port wine stain involving the upper and lower lids (trigeminal or ophthalmic distribution) may be associated with the development of glaucoma. Freezing, surgery, radiation, and tattooing have been tried for the treatment of port wine stains, but PDL treatment is considered the gold standard treatment (Tucci, 2009; Yang, 2005; van Raath, 2020).

Several types of lasers have been used to treat hemangioma, port wine stain, and vascular lesions. The most common in clinical practice is the PDL, which uses yellow light wavelengths (585-600 nm) that selectively penetrate up to 2 millimeters in the skin. Newborns and young children, who have thinner skin, tend to respond well to this type of laser; the response in thicker and darker lesions may be lower. Other types of lasers with greater tissue penetration are used for hypertrophic and resistant port wine stains. Alternatives to the PDL are the long-pulsed 1064 nm Nd:YAG and 755 nm pulsed Alexandrite lasers. Intense pulsed light (IPL) devices emit polychromatic high-intensity pulsed light with a pulse duration in the millisecond range, using an emission spectrum ranging from 500 to 1400 nm. Compared to other types of lasers, IPL devices include both the oxyhemoglobin selective wavelengths emitted by PDL systems and longer wavelengths that allow deeper penetration into the dermis. Several laser systems have been cleared for marketing by the FDA through the 510(k) process for a variety of dermatologic indications, including treatment of port wine stain.

Dermabrasion

Dermabrasion, or surgical skin planing, is a treatment of pre-malignant and malignant skin lesions and acne, which also has cosmetic uses. During this procedure, the skin is mechanically sanded, removing the epidermis to expose the reticular dermis. Treatment is performed to eliminate lesions, improve contour, promote re-epithelialization and achieve a rejuvenated appearance. Salabrasion uses salt impregnated gauze pads to remove the upper layers of skin. Dermabrasion is performed under local or general anesthesia and requires extended recuperation (El-Domyati, 2017).

Microdermabrasion is a less invasive form of dermabrasion, removing only the top layer of skin, the stratum corneum. Microdermabrasion requires no anesthesia and can be repeated within a short period of time. Multiple treatments are frequently needed for results to be apparent. Hydrodermabrasion, a crystal free type of microdermabrasion, typically exfoliates by using a liquid solution spray followed by suction. Microdermabrasion is used in skin rejuvenation and has been used to improve the appearance of melasma, post-acne scarring, striae distensae, and photoaging (El-Domyati, 2016).

Hair Procedures

The most common type of alopecia (hair loss) is androgenetic alopecia. It is typically permanent, hereditary and can affect any gender. There are no health-related ramifications of this condition. The available treatments for alopecia include hairpieces, medications to promote hair growth, and hairplasty.

Hair growth can occur anywhere on the face or body and individual patterns are largely determined by genetic makeup. Hirsutism is a condition defined by excessive terminal hair growth, resulting in coarse and pigmented hair on unexpected areas of the body such as the face, chest, and back (areas considered typical of “male-pattern” hair growth). Hirsutism may arise from excess androgens, primarily testosterone (most commonly associated with polycystic ovary syndrome). The definition of normal body hair must also consider race and ethnicity, as differences in quantities of body hair differ between ethnic groups (for example: most East Asian and Native American women have little body hair, while Mediterranean women on average have substantially greater quantities of body hair even though serum androgen concentrations are similar in the three groups) (Carmina, 1992). Temporary measures to remove hair include waxing, shaving, depilatory creams or medications. Permanent methods include electrolysis or laser hair removal. Electrolysis removes hair permanently by delivering a small electrical current through a needle inserted into the hair follicle which destroys the follicle and prevents regrowth. Laser techniques use concentrated beams of light to destroy the follicle.

The use of hair removal procedures as part of a planned gender affirming surgery is addressed by CG-SURG-27 Gender Affirming Surgery.

Laser and Surgical Treatment of Rosacea and Telangiectasia

Rosacea is a common inflammatory skin disorder characterized by intermittent facial flushing in the center of the face with redness that can slowly spread to the eyes, forehead, nose, cheeks, and chin. Extra-facial lesions involve the ears, chest, and back. In 2017, the National Rosacea Society updated the rosacea classification system developed in 2002. A rosacea diagnosis can be made when at least one diagnostic cutaneous sign or two major phenotypes are present (Gallo, 2017). Permanent telangiectasias may result. Sebaceous hyperplasia, fibrosis and edema (rhinophyma), and ocular involvement characterize more severe forms of the disease. More than 50% of rosacea cases involve ocular manifestations including corneal inflammation, scarring and visual loss due to corneal perforation (Thimboutot, 2020). The treatment of rosacea is dictated by the severity of the disease. Because the diagnosis of rosacea is made on the basis of clinical features, several of which may be common to other skin conditions, differentiation of rosacea from other diseases/conditions may be required. Isolated telangiectasia in the absence of other signs and symptoms are not diagnostic of rosacea. When avoidance of common environmental (sun exposure or temperature changes) or dietary (alcohol, spicy foods) triggers is inadequate, oral antibiotics or topical agents (antibiotics, azelaic acid, isotretinoin, sulfacetamide) are employed. In general, a 12-week trial of topical treatment is used to assess response. Laser treatment and surgical intervention is reserved for cases which are unresponsive to other treatments.

Telangiectasias, also known as spider veins, are abnormally dilated blood vessels associated with a number of diseases such as ataxia-telangiectasia and scleroderma but are mostly benign in nature and due to hereditary or unknown factors. Spider veins may appear anywhere on the body but are most commonly located on the arms, face or legs. Treatment of spider veins may be performed with laser therapy or injection of a sclerosing solution.

Other Cosmetic Skin Procedures

Laser skin resurfacing involves using a strong laser to literally burn away the superficial skin layers in order to remove skin lesions such as pre-cancerous lesions, acne scars, or wrinkles. A number of lasers can be used in treatment. Fractional lasers use a narrow beam of laser light to treat a very specific area while non-fractional laser treatments cover a larger area and are typically more invasive (Verma, 2021). In additional to fractional lasers, ablative lasers have been used for a variety of conditions including scars, pigmentations, and rhytides, as well as for skin resurfacing and rejuvenation. Non-ablative lasers are considered less destructive; they have been used primarily to stimulate new collagen synthesis (Heidari Beigvand, 2020).

Microneedling, also known as percutaneous collagen induction therapy or skin needling, has been proposed as a means of stimulating the body’s regenerative properties to trigger the growth of new skin. The procedure involves rolling a drum shaped device with a cylindrical head imbedded with needles, or a pen shaped device, across the skin to create a series of dermal micro-injuries. Each micro-lesion triggers the wound healing process and the release of several growth factors which stimulate the production and deposition of collagen and elastin within the dermis (Alster, 2018). The disruption of the epidural barrier is minimal, resulting in scarless wound healing. The device can be used alone or with topical products or a fractional microneedling radiofrequency device. The procedure is considered a minimally invasive option to treat conditions such as acne scarring or wrinkles (Alster, 2018; Harris, 2015; Ramaut, 2017).

Tattoos

Tattooing is the permanent injection of ink under the skin for decorative or medical purposes. Tattoos are usually permanent and cannot be removed without invasive interventions such as laser treatment, dermabrasion, or surgical removal. While tattoo removal is usually effective, some scarring or skin discoloration may result from the procedure.

Definitions

Acne vulgaris: The most common form of acne found primarily in adolescents but may be seen in adults.

Actinic keratoses: Common sun-exposure related skin lesions microscopically involving the epidermis alone but with the potential to progress to invasive cancer (squamous cell carcinoma) in a small percentage of cases; also referred to as solar keratoses.

Chemical peels: A group of medical procedures using various chemicals to remove the outer layers of the skin.

Dermabrasion (salabrasion): A group of medical procedures using physical scrubbing methods to remove the outer layer of the skin.

Electrolysis: A procedure designed to permanently remove unwanted hair.

Hairplasty: A surgical procedure designed to transplant or implant hair by taking tiny plugs of skin, containing one to several hairs, from the back or side of the scalp and re-implanting them into areas where hair has been lost, such as in the case of androgenetic baldness. Several transplant sessions may be needed as hereditary hair loss progresses with time.

Hirsutism: A condition defined as excessive terminal hair growth.

Klippel-Trenaunay syndrome: A rare condition present at birth that usually involves port wine stains, excess growth of bones and soft tissue, and varicose veins.

Laser skin resurfacing: A group of medical procedures using laser light methods to remove the outer layer of the skin.

Port wine stain: A congenital hemangioma which is visible as a mark on the skin that resembles port wine in its rich ruby red color. These marks are due to an abnormal aggregation of capillaries in a portion of the skin.

Rosacea: A common dermatologic condition characterized by symptoms of facial flushing and a spectrum of clinical signs, including erythema, telangiectasia, and inflammatory papular or pustular eruptions resembling acne.

Functional impairment: Significant functional impairment may include physical, social, emotional, and psychological impairments or potential impairments. Examples of limits on normal physical functioning include problems with communication, respiration, eating, swallowing, visual impairments, skin integrity, distortion of nearby body parts, or obstruction of an orifice. The cause of the functional impairment may be pain, structural integrity, congenital anomalies or other factors.

Skin lesion: A nonspecific term referring to any change in the skin surface. While some skin lesions represent conditions requiring medical treatment, others do not.

Sturge-Weber syndrome: A rare disorder present at birth with symptoms that include port wine stain birthmark (usually on the face) and nervous system problems; also referred to as encephalotrigeminal angiomatosis.

Telangiectasias: A condition characterized by small, red or blue spider-web marks close to the surface of the skin caused by permanent dilation of small blood vessels. These blood vessels look like thick red lines and may occur in any part of the body, but most commonly are seen on the legs, torso and face; commonly called spider veins.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

A.  Chemical Peels
When Services may be Medically Necessary when criteria are met:

CPT

 

15788-15789

Chemical peel, facial [includes codes 15788, 15789]

15792-15793

Chemical peel, nonfacial [includes codes 15792, 15793]

 

 

ICD-10 Diagnosis

 

C44.00-C44.99

Basal cell, squamous cell, other or unspecified malignant neoplasm of skin

D03.0-D03.9

Melanoma in situ

D04.0-D04.9

Carcinoma in situ of skin

D22.0-D22.9

Melanocytic nevi

D23.0-D23.9

Other benign neoplasm of skin 

D48.5

Neoplasm of uncertain behavior of skin

D49.2

Neoplasm of unspecified behavior of bone, soft tissue, and skin

L57.0

Actinic keratosis

L70.0-L70.9

Acne

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

B.  Cutaneous Hemangiomas and Port Wine Stain
When services may be Medically Necessary or Reconstructive when criteria are met:

CPT

 

17106-17108

Destruction of cutaneous vascular proliferative lesions (eg, laser technique) [includes codes 17106, 17107, 17108]

Note: these codes are specific to the destruction of benign cutaneous vascular proliferative lesions, such as congenital port wine stains, and use of these codes for other lesions is not appropriate.

 

 

ICD-10 Diagnosis

 

D18.00

Hemangioma unspecified site

D18.01

Hemangioma of skin and subcutaneous tissue

D22.0-D22.9

Melanocytic nevi

I78.0-I78.1

Hereditary hemorrhagic telangiectasia, nevus, non-neoplastic 

Q82.5

Congenital non-neoplastic nevus

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when criteria are not met for medically necessary or reconstructive services; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

C.  Dermabrasion, Abrasion
When services are Medically Necessary:

CPT

 

15780-15782

Dermabrasion [includes codes 15780, 15781, 15782]

15786-15787

Abrasion (lesion) [includes codes 15786, 15787]

 

 

ICD-10 Diagnosis

 

C44.00-C44.99

Basal cell, squamous cell, other or unspecified malignant neoplasm of skin

D04.0-D04.9

Carcinoma in situ of skin

L57.0

Actinic keratosis

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

When Services are also Cosmetic and Not Medically Necessary:

CPT

 

15783

Dermabrasion; superficial, any site (eg, tattoo removal)

 

 

ICD-10 Diagnosis

 

 

All diagnoses

D.  Hair Procedures
When services may be Medically Necessary when criteria are met:

CPT

 

17380

Electrolysis epilation, each ½ hour

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as permanent hair removal by laser]

 

 

ICD-10 Procedure

 

0HDSXZZ

Extraction of hair, external approach

 

 

ICD-10 Diagnosis

 

L05.01-L05.92

Pilonidal cyst and sinus

L72.11-L72.12

Pilar and trichodermal cyst

L73.9

Follicular disorder, unspecified

When services are Cosmetic and Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met, for all other diagnoses not listed, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

When services are also Cosmetic and Not Medically Necessary:

CPT

 

15775, 15776

Punch graft for hair transplant

 

 

ICD-10 Procedure

 

0HRSX7Z

Replacement of hair with autologous tissue substitute, external approach

0HRSXJZ

Replacement of hair with synthetic substitute, external approach

0HRSXKZ

Replacement of hair with nonautologous tissue substitute, external approach

 

 

ICD-10 Diagnosis

 

 

All diagnoses

E.  Laser and Surgical Treatment of Rosacea and Telangiectasia
When Services may be Medically Necessary when criteria are met:

CPT

 

96999

Unlisted special dermatological service or procedure [when specified as laser treatment, pulsed dye laser or light treatment]

 

 

ICD-10 Diagnosis

 

L71.0-L71.9

Rosacea

When services are Cosmetic and Not Medically Necessary:
For the procedure and diagnosis codes listed above when medically necessary criteria are not met, for telangiectasia diagnosis listed below, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

ICD-10 Diagnosis

 

I78.0-I78.1

Hereditary hemorrhagic telangiectasia, nevus, non-neoplastic 

When Services are also Cosmetic and Not Medically Necessary:

CPT

 

36468

Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk

 

 

ICD-10 Diagnosis

 

 

All diagnoses

F.  Other services
When services are Cosmetic and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

CPT

 

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as laser skin resurfacing, tattoo removal (other than by dermabrasion), or microneedling]

 

 

ICD-10 Diagnosis

 

 

All diagnoses

G.  Tattooing
When services are Medically Necessary:

CPT

 

11920-11922

Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation [includes codes 11920, 11921, 11922]

 

 

ICD-10 Procedure

 

3E00XMZ

Introduction of pigment into skin and mucous membranes, external approach 

 

 

ICD-10 Diagnosis

 

C00.0-C49.9

Malignant neoplasms

C51.0-C79.72

Malignant neoplasms

C79.82-C96.9

Malignant neoplasms

D00.00-D04.9

Carcinoma in situ

D06.0-D09.9

Carcinoma in situ

D37.01-D48.5

Neoplasm of uncertain behavior

D48.7-D48.9

Neoplasm of uncertain behavior

Z51.0

Encounter for antineoplastic radiation therapy

Z85.00-Z85.29

Personal history of malignant neoplasm

Z85.40-Z85.9

Personal history of malignant neoplasm

When services may be Medically Necessary or reconstructive when criteria are met:
For the procedure codes listed above for the following diagnoses:
Note: for criteria for breast reconstruction, see SURG.00023

ICD-10 Diagnosis

 

C50.011-C50.929

Malignant neoplasm of breast

C79.81

Secondary malignant neoplasm of breast

D05.00-D05.92

Carcinoma in situ of breast

D48.60-D48.62

Neoplasm of uncertain behavior of breast

Z85.3

Personal history of malignant neoplasm of breast

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when medically necessary or reconstructive criteria are not met; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

References

Peer Reviewed Publications:

1. Alster TS, Graham PM. Microneedling: A review and practical guide. Dermatol Surg. 2018; 44(3):397-404.
2. Badawy EA, Kanawati MN. Effect of hair removal by Nd: YAG laser on the recurrence of pilonidal sinus. J Eur Acad Dermatol Venereol. 2009; 23(8):883-886.
3. Carmina E, Koyama T, Chang L, et al. Does ethnicity influence the prevalence of adrenal hyperandrogenism and insulin resistance in polycystic ovary syndrome? Am J Obstet Gynecol. 1992; 167(6):1807-1812.
4. Castineiras I, Del Pozo J, Mazaira M, et al. Actinic cheilitis: evolution to squamous cell carcinoma after carbon dioxide laser vaporization. A study of 43 cases. J Dermatolog Treat. 2010; 21(1):49-53.
5. Conlon JD, Drolet BA. Skin lesions in the neonate. Pediatr Clin North Am. 2004; 51(4):863-888, vii-viii.
6. Conroy FJ, Kandamany N, Mahaffey PJ. Laser depilation and hygiene: preventing recurrent pilonidal sinus disease. J Plast Reconstr Aesthet Surg. 2008; 61(9):1069-1072.
7. El-Domyati M, Hosam W, Abdel-Azim E, et al. Microdermabrasion: a clinical, histometric, and histopathologic study. J Cosmet Dermatol. 2016; 15(4):503-513.
8. Faurschou A, Togsverd-Bo K, Zachariae C, Haedersdal M. Pulsed dye laser vs. intense pulsed light for port-wine stains: a randomized side-by-side trial with blinded response evaluation. Br J Dermatol. 2009; 160(2):359-364.
9. Garzon MC, Huang JT, Enjolras O, Frieden IJ. Vascular malformations. Part II: associated syndromes. J Am Acad Dermatol. 2007; 56(4):541-564.
10. Glick ZR, Frieden IJ, Garzon MC, et al. Diffuse neonatal hemangiomatosis: an evidence-based review of case reports in the literature. J Am Acad Dermatol. 2012; 67(5):898-903.
11. Gold MH, Nestor MS. Current treatments of actinic keratoses. J Drugs Dermatol. 2006; 5(2) Suppl):17-25.
12. Hamilton FL, Car J, Lyons C, et al. Laser and other light therapies for the treatment of acne vulgaris: systematic review. Br J Dermatol. 2009; 160(6):1273-1285.
13. Harris AG, Naidoo C, Murrell DF. Skin needling as a treatment for acne scarring: An up-to-date review of the literature. Int J Womens Dermatol. 2015; 1(2):77-81.
14. Hartzell LD, Buckmiller LM. Current management of infantile hemangiomas and their common associated conditions. Otolaryngol Clin North Am. 2012; 45(3):545-556, vii.
15. Heidari Beigvand H, Razzaghi M, Rostami-Nejad M, et al. Assessment of laser effects on skin rejuvenation. J Lasers Med Sci. 2020; 11(2):212-219.
16. Huikeshoven M, Koster PH, de Borgie CA, et al. Redarkening of port-wine stains 10 years after pulsed-dye-laser treatment. N Engl J Med. 2007; 356(12):1235-1240.
17. Jasim ZF, Handley JM. Treatment of pulsed dye laser-resistant port wine stain birthmarks. J Am Acad Dermatol. 2007; 57(4):677-682.
18. Jeon H, Bernstein LJ, Belkin DA, et al. Pulsed dye laser treatment of port-wine stains in infancy without the need for general anesthesia. JAMA Dermatol. 2019; 155(4):435-441.
19. Jiang SB, Levine VJ, Nehal KS, et al. Er: YAG laser for the treatment of actinic keratoses. Dermatol Surg. 2000; 26(5):437-440.
20. Karimipour DJ, Karimipour G, Orringer JS. Microdermabrasion: an evidence-based review. Plast Reconstr Surg. 2010; 125(1):372-377.
21. Kravvas G, Al-Niaimi F. A systematic review of treatments for acne scarring. Part 1: Non-energy-based techniques. Scars Burn Heal. 2017; 3:2059513117695312.
22. McIntyre WJ, Downs MR, Bedwell SA. Treatment options for actinic keratoses. Am Fam Physician. 2007; 76(5):667-671.
23. Minkis K, Geronemus RG, Hale EK. Port wine stain progression: a potential consequence of delayed and inadequate treatment? Lasers Surg Med. 2009; 41(6):423-426.
24. Neuhaus IM, Zane LT, Tope WD. Comparative efficacy of nonpurpuragenic pulsed dye laser and intense pulsed light for erythematotelangiectatic rosacea. Dermatol Surg. 2009; 35(6):920-928.
25. Oram Y, Kahraman F, Karincaoglu Y, Koyuncu E. Evaluation of 60 patients with pilonidal sinus treated with laser epilation after surgery. Dermatol Surg. 2010; 36(1): 88-91.
26. Ormerod A, Rajpara S. Basal cell carcinoma. Clin Evid (Online). 2008; pii: 1719.
27. Otley, CC, Roenigk, RK. Medium-depth chemical peeling. Semin Cutan Med Surg. 1996; 15(3):145-154.
28. Patel AM, Chou EL, Findeiss L, Kelly KM. The horizon for treating cutaneous vascular lesions. Semin Cutan Med Surg. 2012; 31(2):98-104.
29. Quaedvlieg PJ, Tirsi E, Thissen MR, Krekels GA. Actinic keratosis: how to differentiate the good from the bad ones? Eur J Dermatol. 2006; 16(4):335-339.
30. Ramaut L, Hoeksema H, Pirayesh A, et al. Microneedling: Where do we stand now? A systematic review of the literature. J Plast Reconstr Aesthet Surg. 2018; 71(1):1-14.
31. Sami NA, Attia AT, Badawi AM. Phototherapy in the treatment of acne vulgaris. J Drugs Dermatol. 2008; 7(7):627-632.
32. Semkova K, Kazandjieva J, Kadurina M, Tsankov N. Hemangioma Activity and Severity Index (HASI), an instrument for evaluating infantile hemangioma: development and preliminary validation. Int J Dermatol. 2015; 54(4):494-498.
33. Tucci FM, De Vincentiis GC, Sitzia E, et al. Head and neck vascular anomalies in children. Int J Pediatr Otorhinolaryngol. 2009; 73 Suppl 1:S71-S76.
34. van Raath MI, Chohan S, Wolkerstorfer A, et al. Treatment outcome measurement instruments for port wine stains: a systematic review of their measurement properties. Dermatology. 2020; 1-17.
35. van Zuuren EJ, Gupta AK, Gover MD, et al. Systematic review of rosacea treatments. J Am Acad Dermatol. 2007; 56(1):107-115.
36. Yang MU, Yaroslavsky AN, Farinelli WA, et al. Long-pulsed neodymium: yttrium-aluminum-garnet laser treatment for port-wine stains. J Am Acad Dermatol. 2005; 52(3 Pt 1):480-490.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Bickers DR, Lim HW, Margolis D, et al. American Academy of Dermatology Association; Society for Investigative Dermatology. The burden of skin diseases: 2004 joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology. J Am Acad Dermatol. 2006; 55(3):490-500.
2. Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations. Available at: https://www.cms.gov/medicare-coverage-database/search.aspx?redirect=Y&from=Overview. Accessed on April 20, 2022.
   • Laser Procedures. NCD #140.5. Effective May 1, 1997.
   • Treatment of Actinic Keratosis (AKs). NCD #250.4. Effective November 26, 2001.
3. Darrow DH, Greene AK, Mancini AJ, Nopper AJ; Section on Dermatology, Section on Otolaryngology–Head And Neck Surgery, and Section on Plastic Surgery. Diagnosis and management of infantile hemangioma. Pediatrics. 2015; 136(4):e1060-e1104.
4. de Berker D, McGregor JM, Hughes BR. British Association of Dermatologists Therapy Guidelines and Audit Subcommittee. Guidelines for the management of actinic keratoses. Br J Dermatol. 2007; 156(2):222-230.
5. Faurschou A, Olesen AB, Leonardi-Bee J, et al. Lasers or light sources for treating port-wine stains. Cochrane Database Syst Rev. 2011;(11):CD007152.
6. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018; 78(1):148-155.
7. International Society for the Study of Vascular Anomalies (ISSVA). ISSVA Classification for Vascular Anomalies. 2018. Available at: http://www.issva.org/content.aspx?page_id=22&club_id=298433
   &module_id=152904. Accessed on April 20, 2022.
8. Khunger N, Mysore V, Savant S, et al. The IADVL Task Force. Standard guidelines of care for acne surgery. Indian J Dermatol Venereol Leprol. 2008; 74 Suppl:S28-S36.
9. Krowchuk DP, Frieden IJ, Mancini AJ, et al. Subcommittee on the management of infantile hemangiomas. Clinical Practice Guideline for the Management of Infantile Hemangiomas. Pediatrics. 2019; 143(1). Available at: https://pediatrics.aappublications.org/content/143/1/e20183475#T4. Accessed on April 20, 2022.
10. Krupashankar DS. IADVL Dermatosurgery Task Force. Standard guidelines of care: CO2 laser for removal of benign skin lesions and resurfacing. Indian J Dermatol Venereol Leprol. 2008; 74 Suppl:S61-S67.
11. National Comprehensive Cancer Network® NCCN Clinical Practice Guidelines in Oncology®. ©2022 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on May 4, 2022.
    • Basal Cell Skin Cancer V2.2022. Revised March 24, 2022.
    • Squamous Cell Skin Cancer V1.2022. Revised May 4, 2022.
12. Poulin Y, Lynde CW, Barber K, et al; Canadian non-Melanoma Skin Cancer Guidelines Committee. Non-melanoma Skin Cancer in Canada Chapter 3: Management of Actinic Keratoses. J Cutan Med Surg. 2015; 19(3):227-238.
13. Thiboutot D, Anderson R, Cook-Bolden F, et al. Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2020; 82(6):1501-1510.
14. van Zuuren EJ, Graber MA, Hollis S, et al. Interventions for rosacea. Cochrane Database Syst Rev. 2005;(3): CD003262.
15. Verma N, Yumeen S, Raggio BS. Ablative Laser Resurfacing. 2020 Aug 13. In: StatPearls [Internet]. 2021 Available at: https://www.ncbi.nlm.nih.gov/books/NBK557474/. Accessed on April 20, 2022.
16. Zalaudek I, Kreusch J, Giacomel J, et al. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part II. Nonmelanocytic skin tumors. J Am Acad Dermatol. 2010; 63(3):377-386.

Websites for Additional Information

1. American Academy of Dermatology (AAD). Available at: http://www.aad.org/. Accessed on April 20, 2022.
2. American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Available at: http://www.abfprs.org/. Accessed on April 20, 2022.
3. American Academy of Pediatrics (AAP). Infantile Hemangiomas. Updated on December 24, 2018. Available at: https://www.healthychildren.org/English/health-issues/conditions/skin/Pages/Birthmarks-Hemangiomas.aspx . Accessed on April 20, 2022.
4. American Cancer Society (ACS). Detailed guide. Skin cancer: basal and squamous cell. http://www.cancer.org/acs/groups/cid/documents/webcontent/003139-pdf.pdf . Accessed on April 20, 2022.
5. The Aesthetic Society. Available at: http://surgery.org. Accessed on April 20, 2022.
6. American Society of Plastic Surgeons (ASPS). Available at: http://www.plasticsurgery.org. Accessed April 20, 2022.

Index

Candela Vbeam® PDL System
Cynergy™ Multiplex Dual Vascular Laser Esteflash3 IPL System
Hydrafacial
Hydrodermabrasion
Lumenis IPL and IPL/Nd:Yag Laser Systems
Lumenis ResurEX
Mediflash3 IPL System
Microdermabrasion
NannoLight IPL System
Percutaneous Collagen Induction Therapy

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History

Status

Date

Action

Revised

05/12/2022

Medical Policy & Technology Assessment Committee (MPTAC) review. Revised Hair Procedures position statement to remove reference to gender specific alopecia and to remove the hair removal example. Updated Description, Background, Definitions and References sections.

Revised

05/13/2021

MPTAC review. Removed term “physical” from the term “physical functional impairment” in chemical peels, cutaneous hemangioma, port wine stain, and other vascular lesions, dermabrasion, hair procedures, laser and surgical treatment of rosacea and telangiectasia position statements. Updated Background, Definitions and References sections.

 

04/07/2021

Revised Medically Necessary definition text in the Description section.

Revised

05/14/2020

MPTAC review. Information related to dermal fillers and collagen injections removed from this document and now addressed in MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures. Updated Position Statement, Background/Overview, Definitions, References and Websites and History sections. Updated Coding section; removed codes 11950, 11951, 11952, 11954, G0429, Q2026, Q2028.

Reviewed

06/06/2019

MPTAC review. Updated Background, References and Websites sections.

Revised

07/26/2018

MPTAC review. Added microneedling as a cosmetic and not medically necessary indication. Updated Background, References and Websites sections.

 

12/27/2018

The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2018 CPT descriptor revision for 36468.

Reviewed

08/03/2017

MPTAC review. Updated Coding, References, Websites and Index sections.

 

01/01/2017

Updated Coding section to remove HCPCS code C9800 deleted 12/31/2016.

Reviewed

08/04/2016

MPTAC review. Updated Background, References, and Websites sections. Removed CPT code 36469 deleted 12/31/2014 and ICD-9 codes from Coding section.

Revised

08/06/2015

MPTAC review. Minor format changes to Position Statements without revision to criteria. Updated Description, Rationale, Background, References, and Websites sections.

Reviewed

08/14/2014

MPTAC review. Minor format changes to Position Statements without revision to criteria. Other format changes and updates to Description, Rationale, Background, References, and Websites for Additional Information sections.

 

01/01/2014

Updated Coding section with 01/01/2014 HCPCS changes; removed Q2027 deleted 12/31/2013.

Reviewed

08/08/2013

MPTAC review. Updated Background, Coding, References, Websites for Additional Information, and Index sections.

Revised

08/09/2012

MPTAC review. Clarified medically necessary and cosmetic and not medically necessary statements: D. Laser and Surgical Treatment of Rosacea and Telangiectasia; added reconstructive statement: E. Tattoos (Application); added medically necessary statement, revised reconstructive and cosmetic and not medically necessary statement: G. Cutaneous Hemangioma, Port Wine Stain, and other Vascular Lesions; added medically necessary statement and combined and revised cosmetic and not medically necessary statement: H. Hair Procedures; and, clarified cosmetic and not medically necessary statement: I. Other Cosmetic Skin Procedures. Updated Background, Coding, Definitions, References, Websites for Additional Information and Index.

Revised

02/16/2012

MPTAC review. Clarified Position Statements for specific indications and removed section: Treatment of Keloids and Scar Revisions and related codes from the Coding section. Added Cosmetic and Not Medically Necessary statement to sections: F. Injection of Dermal Fillers and G. Port Wine Stain. Updated Description, Background, Definitions, Index, and References.

 

10/01/2011

Updated Coding section with 10/01/2011 ICD-9 changes.

Reviewed

02/17/2011

MPTAC review. Updated and reformatted Background, Definitions, Coding, References and Websites for Additional Information.

 

10/01/2010

Updated Coding section with 10/01/2010 HCPCS changes; removed HCPCS S0196 deleted 09/30/2010.

 

07/01/2010

Updated Coding section with 07/01/2010 HCPCS changes.

Revised

02/25/2010

MPTAC review. Clarified Position Statements. Revised medically necessary statement for Dermabrasion, removing criteria for 10 lesions and treatment failure. Removed rhinophyma statement from Laser and Surgical Treatment of Acne Rosacea. Updated Description, Background, Coding, References, and Index.

 

01/01/2010

Updated Coding section with 01/01/2010 CPT changes; removed CPT 14300, deleted 12/31/2009.

Revised

02/26/2009

MPTAC review. Removed cryotherapy and chemical exfoliation for acne from the medically necessary statement. Updated Discussion and References. Updated Coding section; removed CPT 17340, 17360.

Reviewed

11/20/2008

MPTAC review. References and Background updated.

 

10/01/2008

Updated Coding section with 10/01/2008 ICD-9 changes.

 

04/01/2008

A NOTE was added after the Reconstructive definition to clarify that not all benefit contracts include a reconstructive services benefit.

Revised

11/29/2007

MPTAC review. Clarified/reformatted Description section and Position Statements for Chemical Peels and Cryotherapy, Laser and Surgical Treatment of Acne Rosacea and Other Cosmetic Skin Procedures. Addition of cosmetic and not medically necessary statement to Tattoos section. Revision of Position Statement section from: Injection of Poly-L-Lactic Acid to Injection of Dermal Fillers; addition of Radiesse, an FDA-approved dermal filler for lipodystrophy. Updated Rationale, Background, Definitions, Coding, References and Index. The phrase “cosmetic/not medically necessary” was clarified to read “cosmetic and not medically necessary.”

Reviewed

12/07/2006

MPTAC review. References updated. Coding updated; removed CPT 15810, 15811 deleted 12/31/2005.

Revised

12/01/2005

MPTAC revised. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

 

11/22/2005

Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).

Reviewed

09/22/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

01/13/05

ANC.00007

Cosmetic & Reconstructive Services: Skin Related

Anthem Virginia

06/28/02

VA Memo 1108

Radiation Treatment of Keloids

WellPoint Health Networks, Inc.    

06/24/04

2.02.02

Chemical Peels

 

09/23/04

09.03.01

Treatment of Alopecia

 

09/23/04

Definitions iii

Definition: Cosmetic vs. Reconstructive Services

 

12/2/04

 

Clinical Document: Management of Rosacea

 

 

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage.  The member’s contract benefits in effect on the date that services are rendered must be used.  Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.  Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.
 
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.
 
© CPT Only – American Medical Association

The requirements below are specific to the Florida Medicaid Managed Care Plan and are not a part of the Medical Policy or Clinical UM guideline approved by Elevance Health’s Medical Policy and Technology Assessment Committee.
 
If the Florida Medicaid Managed Care Plan intends to deny coverage on the basis that a diagnostic test, therapeutic procedure, or medical device or technology is experimental or investigational, the Managed Care Plan shall submit a request for coverage determination to the Agency in accordance with rule 59G-1.035, F.A.C and Core SMMC Contract, Attachment II, Section VI.G.4.d.
 
Below is a list of the materials the plans are required to submit when they deny coverage as experimental/investigational: 

1. Include the CPT or HCPCS code(s)  

2. Include a list of other state Medicaid agencies and private insurers who cover the service  

3. Include information about the health service from the U.S. Food and Drug Administration  

4. Include known risks of the service and health outcomes of others who have received it  

5. Include a list of covered alternative services, if any, that could be used to treat the condition  

6. Identify a specific recipient needing the service  

7. Include the recipient’s health history  

8. Include the disease information necessitating the requested service  

9. Include a rationale for the immediacy of the review  

Additional required information 

1. Submit the rationale used to preliminarily indicate the service is experimental/investigational

   1. Include peer-reviewed journal articles in PDF format with links to the online articles  

   2. Include evidence-based clinical guidelines reviewed by the plan  

2. Submit direct contact information (name, phone number, & email address) for the Medical Director