Removal of Implantable Devices Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 27 500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM 848 WWW.BCBSRI.COM EFFECTIVE DATE: 08|01|2025 POLICY LAST UPDATED: 04|02|2025 OVERVIEW The intent of this policy is to document the criteria and prior authorization requirement for the removal of surgically implanted devices. MEDICAL CRITERIA Medicare Advantage Plans and Commercial Products Removal Only Removal Only of a surgically implanted device is considered medically necessary when: • the insertion of the device was determined to be medically necessary. Removal Only of a surgically implanted device is considered medically necessary when: • the insertion of the device was determined to be NOT medically necessary, and one of the following indications is present: o complication, OR o infection Removal and Reinsertion, Replacement or Revision of a Device
In instances where the appropriate Current Procedural Terminology (CPT) code for removal of a device represents the removal AND/OR reinsertion, replacement or revision of a device: • the removal must be reviewed using the above removal criteria, • the reinsertion/replacement/revision must be reviewed to determine medical necessity. o Note: In most instances, the criteria from the Medical Necessity policy would be used for review of reinsertion/replacement/revision. However, in other instances, a medical policy may exist for the specific device, or the New Technology and Miscellaneous Services policies can be referenced. Please see Related Policies section. PRIOR AUTHORIZATION
Medicare Advantage Plans and Commercial Products Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products and is obtained via the online tool for participating providers. See the Related Policies section. POLICY STATEMENT Medicare Advantage Plans and Commercial Products Removal of a surgically implanted device is considered medically necessary when medical criteria are met. Reimplantation of the device is considered not medically necessary, when the initial implantation was determined to be not medically necessary. COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable surgery benefits/coverage. Medical Coverage Policy | Removal of Implantable Devices

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 27
500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM 848 WWW.BCBSRI.COM

BACKGROUND Not applicable

CODING The following codes, in the attached grid below, are covered when applicable medical criteria are met for Medicare Advantage Plans and Commercial Products coverage.

2025 Removal of Implantable Devices

RELATED POLICIES Bariatric Surgery Baroreflex Stimulation Devices Centers for Medicare and Medicaid Services National and Local Coverage Determinations Coverage of Complications Following a Non-Covered Service
Gastric Electrical Stimulation – Insertion Glucose Monitoring – Continuous Implantable Bone Conduction and Bone Anchored Hearing Aids Implantation of Anterior Segment Intraocular Nonbiodegradable Drug-Eluting System Medical Necessity Medicare Advantage Plans National and Local Coverage Determinations New Technology and Miscellaneous Services Percutaneous and Subcutaneous Tibial Nerve Stimulation
Phrenic Nerve Stimulation for Central Sleep Apnea Prior Authorization of Cardiology and Radiology Services Prior Authorization via Web-Based Tool for Procedures
Spinal Cord Stimulation Subtalar Arthroereisis

PUBLISHED Provider Update, June 2025 Provider Update, March/August 2024 Provider Update, January/April 2023 Provider Update, May/December 2022 Provider Update, April 2021

REFERENCES Not applicable

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS