15828 - TMHP REMOVAL OF NECK WRINKLES Chemical peel, nonfacial; epidermal Dermabrasion; regional, other than face Abrasion; single lesion (eg, keratosis, scar) Subcutaneous injection of filling material (eg, collagen); 1 cc or less Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc Subcutaneous injection of filling material (eg, collagen); over 10.0 cc Replacement of tissue expander with permanent prosthesis Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad GOOD Suction assisted lipectomy; head and neck GOOD - Per TMHP Manual maybe covered for injury or trauma Good - Per TMHP Manual maybe covered for injury or trauma Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure) Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure) Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less Formation of direct or tubed pedicle, with or without transfer; trunk Punch graft for hair transplant; 1 to 15 punch grafts Punch graft for hair transplant; more than 15 punch grafts Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure) Dermabrasion; segmental, face Dermabrasion; superficial, any site (eg, tattoo removal) Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure) Chemical peel, facial; epidermal Chemical peel, facial; dermal Chemical peel, nonfacial; dermal Cervicoplasty Rhytidectomy; forehead Rhytidectomy; glabellar frown lines Rhytidectomy; cheek, chin, and neck Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy CPT BOOK Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area CPT Book Graft for facial nerve paralysis; free muscle graft (including obtaining graft) Graft for facial nerve paralysis; free muscle flap by microsurgical technique Graft for facial nerve paralysis; regional muscle transfer Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) Suction assisted lipectomy; trunk Suction assisted lipectomy; upper extremity Suction assisted lipectomy; lower extremity Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions Chemical cauterization of granulation tissue (ie, proud flesh) Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter over 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 4.0 cm Electrolysis epilation, each 30 minutes NONCovered for STAR - is on Noncovered and PA Flag Noncovered for CHIP Mastopexy Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition Open periprosthetic capsulotomy, breast Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Nipple/areola reconstruction Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion Preparation of moulage for custom breast implant Periprosthetic capsulectomy, breast Removal of intact mammary implant Removal of mammary implant material Revision of reconstructed breast Correction of inverted nipples Need STAR PA flag set Good Tissue grafts, other (eg, paratenon, fat, dermis) Not covered for STAR CPT Book TMHP Per TMHP is covered for 20 years of age & younger w/ certain dx codes NON Covered Genioplasty; augmentation (autograft, allograft, prosthetic material) Genioplasty; sliding osteotomy, single piece Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) Augmentation, mandibular body or angle; prosthetic material Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) Reduction forehead; contouring only Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) Reduction forehead; contouring and setback of anterior frontal sinus wall Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) Osteoplasty, facial bones; reduction Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) Malar augmentation, prosthetic material Medial canthopexy (separate procedure) Lateral canthopexy Reconstructive repair of pectus excavatum or carinatum; open Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy Repair macrodactylia, each digit Excision or surgical planing of skin of nose for rhinophyma Rhinectomy; partial Rhinectomy; total Revision of tracheostomy scar Selective catheter placement, venous system; first order branch (eg, renal vein, jugular vein) Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein) Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk Injection of sclerosant; single incompetent vein (other than telangiectasia) Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; initial artery Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; each additional artery (List separately in addition to code for primary procedure) Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein (List separately in addition to code for primary procedure) Code deleted 01/01/2016 Intravascular ultrasound (non-coronary vessel) during diagnostic evaluation and/or therapeutic intervention; initial vessel (List separately in addition to code for primary procedure) Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to code for primary procedure) Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS) Ligation, division, and stripping, short saphenous vein Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when performed, open,1 leg Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) Vermilionectomy (lip shave), with mucosal advancement Excision of lip; transverse wedge excision with primary closure Excision of lip; V-excision with primary direct linear closure xcision of lip; full thickness, reconstruction with local flap (eg, Estlander or fan) Excision of lip; full thickness, reconstruction with cross lip flap (Abbe-Estlander) Resection of lip, more than one-fourth, without reconstruction Umbilectomy, omphalectomy, excision of umbilicus (separate procedure) Repair initial incisional or ventral hernia; reducible Repair initial incisional or ventral hernia; incarcerated or strangulated Repair recurrent incisional or ventral hernia; reducible Repair recurrent incisional or ventral hernia; incarcerated or strangulated Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair) Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck Insertion of testicular prosthesis (separate procedure) Plastic repair of introitus Perineoplasty, repair of perineum, nonobstetrical (separate procedure) Codes noticed on noncovered list that should not be Construction of artificial vagina; without graft Construction of artificial vagina; with graft Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach Repair of blepharoptosis; (tarso) levator resection or advancement, external approach Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type) Reduction of overcorrection of ptosis Ear piercing Good - Non covered TMHP Good Interdental wiring, for condition other than fracture Gingivectomy, excision gingiva, each quadrant Operculectomy, excision pericoronal tissues Excision of hyperplastic alveolar mucosa, each quadrant (specify) Correction of lid retraction Repair of ectropion; excision tarsal wedge Repair of ectropion; extensive (eg, tarsal strip operations) Repair of entropion; excision tarsal wedge Repair of entropion; extensive (eg, tarsal strip or capsulopalpebral fascia repairs operation) Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; over one-fourth of lid margin Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; up to two-thirds of eyelid, 1 stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, lower, 1 stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, upper, 1 stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; second stage Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring total hysterectomy Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof CPT Book

This procedure appears on the selected insurer prior authorization source.