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Medicare Advantage Prior Authorization
Reconstructive and Plastic Surgery

last updated 12/01/2009 garcarl

15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad 
15822 Blepharoplasty, upper eyelid;
15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid 
15824 Rhytidectomy; forehead 
15826 Rhytidectomy; glabellar frown lines 
15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy 
17106 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm 
17107 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm
17108 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm 
19300 Mastectomy for gynecomastia 
19316 Mastopexy
19318 Reduction mammaplasty 
19324 Mammaplasty, augmentation; without prosthetic implant 
19325 Mammaplasty, augmentation; with prosthetic implant 
19328 Removal of intact mammary implant
19330 Removal of mammary implant material 
19355 Correction of inverted nipples 
19370 Open periprosthetic capsulotomy, breast 
19371 Periprosthetic capsulectomy, breast 
67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) 
67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) 
67902 Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia
67903 Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach 
67904 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach
67906 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) 
67908 Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type)
67909 Reduction of overcorrection of ptosis 

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