Does C1789 require prior authorization?

No, C1789 does not require prior authorization (high confidence). Code is covered without prior authorization.

`C1789`, Prosthesis, breast (implantable)

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Inferred: clinical documentation of the indication for reconstruction (e.g., mastectomy or other reason for reconstruction) and patient-specific factors influencing choice of reconstruction (age, body composition, general health status, planned cancer treatment).
Inferred: operative reports and clinical notes for initial reconstruction and any subsequent revision surgeries, including description of donor sites when autologous tissue is used.
Inferred: documentation of asymmetry and clinical rationale for contralateral breast procedures (mastopexy, reduction, augmentation) to improve symmetry.
Inferred: clinical documentation supporting implant-related complications (e.g., signs/symptoms and diagnosis of capsular contracture) when requesting capsulotomy or capsulectomy.

Breast reconstruction surgery rebuilds a breast's shape following a mastectomy or trauma
may be performed immediately, be delayed or be completed in stages
using autologous tissue taken from other areas of an individual's body (abdomen, back, buttocks, thighs)
placing an artificial implant
using a tissue expander if necessary, depending on the final desired breast size
Breast reconstruction (autologous tissue or implants) depending on an individual's age, body composition, general health status, method of planned cancer treatment or other reason for reconstruction.

HUMANA-BREAST-PROCEDURES-SC-MEDICAID, Breast Procedures

ANTHEM-SURG.00023, Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

BCBSIL-SUR716.011, Reconstructive Breast Surgery

BCBSMT-SUR716.011, Reconstructive Breast Surgery

BCBSNM-SUR716.011, Reconstructive Breast Surgery

Ask Backwork about documentation requirements, denial risks, or coverage in your state.