Starting Dec. 4, 2022, hair removal procedures including electrolysis and laser will require specific prior authorization documentation. Requirements and coverage limitations will be as follows:
Referral requests
- Prior to initial referral and every 3 (three) months, an evaluation by a PCP or dermatologist or surgeon is required to justify hair removal services. The evaluation should include the following:
- An evaluation of the member for psychological distress related to the presence of unwanted hair and justification of medical necessity of hair removal.
- Body area(s) and photos of body area(s) that require treatment.
- Referral for follow-up visit with hair removal provider.
Laser hair removal procedure requests
- Diagnosis and documentation justifying hair removal services for specific body areas (face/neck, back, chest, abdomen, genitalia).
- Use CPT procedure code 17999 indicating daily treatment per body area (face/neck or back or chest or abdomen or genitalia – each representing 1 (one) body area).
- Maximum 1 (one) CPT 17999 units per day per body area; 3 (three) units CPT 17999 in 3 (three)-month period per body area.
- Frequency of treatment visits is to be no more frequent than every 4 (four) weeks.
Electrolysis hair removal requests
- Diagnosis and documentation justifying hair removal services for specific body areas (face/neck, back, chest, abdomen, genitalia).
- Electrolysis hair removal is to use CPT procedure code 17380 indicating 30 (thirty) minutes of treatment, all inclusive, regardless of body area being treated.
- Requests are to have a maximum 4 (four) CPT 17380 units per day; 48 (forty-eight) CPT 17380 units in 3 (three) months.
For members receiving care at this time: During the 45-day notice period from Oct. 19, 2022-Dec. 4, 2022, a maximum of 2 (two) 17999 units and 24 (twenty-four) 17380 units will be covered.
Refer to policy 404-1103 – Hair Removal for full details.
Questions? Please contact your Provider Services Representative at 800-700-3874, ext. 5504.
