N.Y. Comp. Codes R. & Regs. tit. 11 § 56.3

Current through Register Vol. 46, No. 53, December 31, 2024

Section 56.3 - Claim review requirements for surgical services

(a) A claim or request for coverage of reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child that has resulted in a functional defect shall not be considered by a health plan to be cosmetic. Reconstructive surgery may however be reviewed for medical necessity subject to the requirements of titles I and II of article 49 of the Insurance Law or Public Health Law.

(b) A claim or request for coverage of surgery other than for the surgical services described in subdivision (a) or (c) of this section that is considered by a health plan to be cosmetic shall be reviewed for medical necessity subject to the requirements of titles I and II of article 49 of the Insurance Law or Public Health Law.

(c) A claim or request for coverage of surgery, other than a request for pre-authorization, that is solely identified by one of the codes in subdivision (f) of this section and is submitted to a health plan without any accompanying medical information, may be denied by a health plan as cosmetic without subjecting the request to the requirements of titles I and II of article 49 of the Insurance Law or Public Health Law, provided that:

(1) notice of the denial includes a clear statement describing the basis for the denial;

(2) notice of the denial includes a statement that the insured has a right to a medical necessity review if the insured or the insured's health care provider believes the claim or request involves issues of medical necessity and submits medical information;

(3) if a medical necessity review is requested and medical information is submitted, the health plan treats the request as a utilization review appeal pursuant to section 4904 of the Insurance Law or Public Health Law; and

(4) if the health plan denies coverage of the procedure after receipt of medical information, the health plan issues a final adverse determination in compliance with section 4904 (c) of the Insurance Law and section 410.9(e) of this Title (Regulation 166) or section 4904 (3) of the Public Health Law and 10 NYCRR 98-2.9(e), as applicable.

(d) If an initial claim or request for a procedure listed in subdivision (f) of this section is submitted to a health plan with accompanying medical information, the claim or request shall be reviewed in compliance with titles I and II of article 49 of the Insurance Law or Public Health Law.

(e) If an initial claim or request for a procedure listed in subdivision (f) of this section is submitted to a health plan as a pre-authorization request without accompanying medical information, the necessary information shall be requested as required by section 4905 (k) of the Insurance Law or section 4905 (11) of the Public Health Law and the claim or request shall be reviewed in compliance with titles I and II of article 49 of the Insurance Law or Public Health Law.

(f) Common procedural terminology (CPT code [copyright]) and description.

11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions

11201 Removal of skin tags; each additional 10 lesions

11950 Subcutaneous injection of filling material (e.g., collagen); 1 cc or less

11951 Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc

11952 Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc

11954 Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc

15775 Punch graft for hair transplant; 1 to 15 punch grafts

15776 Punch graft for hair transplant; more than 15 punch grafts

15780 Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids, general keratosis)

15781 Dermabrasion, segmental, face

15782 Dermabrasion, regional, other than face

15783 Dermabrasion, superficial, any site, (e.g., tattoo removal)

15786 Abrasion; single lesion (e.g., keratosis, scar)

15787 Abrasion; each additional four lesions or less

15788 Chemical peel, facial; epidermal

15789 Chemical peel, facial; dermal

15790 Chemical peel; total face

15791 Chemical peel; face, hand or elsewhere

15792 Chemical peel, nonfacial; epidermal

15793 Chemical peel, nonfacial; dermal

15810 Salabrasion; 20 sq. cm or less

15811 Salabrasion; over 20 sq. cm

15819 Cervicoplasty

15820 Blepharoplasty, lower eyelid;

15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad

15824 Rhytidectomy; forehead

15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)

15826 Rhytidectomy; glabellar frown lines

15828 Rhytidectomy; cheek, chin, and neck

15829 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap

15832 Excision, excessive skin and subcutaneous tissue (including lipectomy); thigh

15833 Excision, excessive skin and subcutaneous tissue (including lipectomy); leg

15834 Excision, excessive skin and subcutaneous tissue (including lipectomy); hip

15835 Excision, excessive skin and subcutaneous tissue (including lipectomy); buttock

15836 Excision, excessive skin and subcutaneous tissue (including lipectomy); arm

15837 Excision, excessive skin and subcutaneous tissue (including lipectomy); forearm or hand

15838 Excision, excessive skin and subcutaneous tissue (including lipectomy); submental fat pad

15839 Excision, excessive skin and subcutaneous tissue (including lipectomy); other area

15876 Suction assisted lipectomy; head and neck

15877 Suction assisted lipectomy; trunk

15878 Suction assisted lipectomy; upper extremity

15879 Suction assisted lipectomy; lower extremity

17340 Cryotherapy (CO ₂ slush, liquid N ₂) for acne

17360 Chemical exfoliation for acne (e.g., acne paste, acid)

17380 Electrolysis epilation, each 1/2 hour

19316 Mastopexy

19355 Correction of inverted nipples

21120 Genioplasty; augmentation (autograft, allograft, prosthetic material)

30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work)

36468 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk

36469 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face

36470 Injection of sclerosing solution; single vein

36471 Injection of sclerosing solution; multiple veins, same leg

69090 Ear piercing

69300 Otoplasty, protruding ear, with or without size reduction

S0800 Laser in situ keratomileusis

S0810 Photorefractive keratectomy

S0812 Phototherapeutic keratectomy

65760 Keratomileusis

65765 Keratophakia

65767 Epikeratoplasty

65771 Radial keratotomy

N.Y. Comp. Codes R. & Regs. Tit. 11 § 56.3